Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
57.100 NHSN Registration Form Modified 2000 167 6307 Form CDC 57.100 NHSN Registration Form
57.101 Facility Contact Information Modified 2000 333 12613 Form CDC 57.101 Facility Contact Information
57.103 Patient Safety Component - Annual Hospital Survey Modified 6000 5000 113520 Form CDC 57.103 Patient Safety Component--Annual Hospital Survey
57.105 Group Contact Information Modified 1000 83 3153 Form CDC 57.105 Group Contact Information
57.106 Patient Safety Monthly Reporting Plan Modified 72000 18000 1589280 Form and Instruction CDC 57.106 Patient Safety Monthly Reporting Plan
57.108 Primary Bloodstream Infection (BSI) Modified 264000 132000 5327872 Form CDC 57.108 Primary Bloodstreat Infection (BSI)
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Modified 432000 216000 7900992 Form CDC 57.111 Pneumonia (PNEU)
57.112 Ventilator-Associated Event (VAE) Modified 864000 360000 11987712 Form CDC 57.112 Ventilator-Associated Event (VAE)
57.114 Urinary Tract Infection (UTI) Modified 240000 120000 4389440 Form CDC 57.114 Urinary Tract Infection (UTI)
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Modified 54000 162000 5099760 Form CDC 57.116 Denominators for Neonatal intensive Care Unit (NICU)
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Modified 54000 270000 8449600 Form CDC 57.117 Denominators for Specialty Care Area (SCA) Oncology (ONC)
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Modified 324000 1620000 50997600 Form CDC 57.118 Denominators for Intensive Care Unit (ICU)/Other Locations (not NICU or SCA)
57.120 Surgical Site Infection (SSI) Modified 216000 126000 3950496 Form CDC 57.120 Surgical Site Infection (SSI)
57.121 Denominators for Procedure Modified 3240000 270000 8499600 Form CDC 57.121 Denominator for Procedure
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Modified 72000 6000 107400 Form CDC 57.123 Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Modified 72000 6000 84600 Form and Instruction CDC 57.124 Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables
57.125 Central Line Insertion Practices Adherence Monitoring Form Modified 100000 8333 315333 Form CDC 57.125 Central Line Insertion Practices Adherence Monitoring
57.126 MDRO or CDI Infection Event Modified 432000 216000 7900992 Form CDC 57.126 MDRO or CDI Infection Event
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Modified 144000 36000 1089792 Form CDC 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting
57.128 Laboratory Identified or CDI MDRO Event Modified 1440000 360000 13622400 Form CDC 57.128 Laboratory-identified MDRO or CDI Event
57.130 Vaccination Monthly Monitoring Form - Summary Method Removed 0 0 0 Form 57.130 Vaccination Monthly Monitoring - Summary Method
57.131 Vaccination Monthly Monitoring Form - Patient-Level Method Removed 0 0 0 Form 57.131 Vaccination Monthly Monitoring - Patient level
57.133 Patient Vaccination Removed 0 0 0 Form 57.133 Patient Vaccination
57.137 Long Term care Facility Component--Annual Facility Survey Modified 250 250 7095 Form CDC 57.137 Long Term Care Facility Component---Annual Facility Survey
57.138 Laboratory-Identified MDRO or CDI Event for LTCF Modified 2000 500 18920 Form CDC 57.138 Laboratory-identified MDRO or CDI Event for LTCF
57.139 MDRO and CDI Monthly Monitoring for LTCF Modified 3000 250 9460 Form CDC 57.139 MDRO and CDI Monthly Monitoring for LTCF
57.140 Urinary Tract Infection (UTI) for LTCF Modified 2250 1125 38313 Form CDC 57.140 Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF Modified 3000 250 9460 Form CDC 57.141 Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations Modified 3000 9750 340560 Form CDC 57.142 Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF Modified 3000 250 9460 Form CDC 57.143 Prevention Process Measures Monthly Monitoring
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Modified 400 333 7568 Form CDC 57.150 Patient Safety Component---Annual Facility Survey for LTAC
57.151 Patient Safety Component -- Annual Facility Survey for IRF Modified 1000 833 15767 Form CDC 57.151 Patient Safety Component---Annual Facility Survey for IRF
57.200 Healthcare Personnel Safety Component Facility Survey Modified 50 400 15940 Form CDC 57.200 Healthcare Personnel Safety - Annual Facility Survey
57.203 Healthcare Personnel Safety Reporting Plan Modified 11000 917 73064 Form CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan
57.204 Healthcare Worker Demographic Data Modified 10000 3333 132833 Form CDC 57.204 Healthcare Worker Demographic Data
57.205 Exposure to Blood and Body Fluids Modified 2500 2500 99625 Form CDC 57.205 Exposure to Blood/Body Fluids
57.206 Healthcare Worker Prophylaxis/Treatment Modified 1500 375 14944 Form CDC 57.206 Healthcare Worker Prophylaxis/Treatment
57.207 Follow-up Laboratory Testing Modified 2500 625 11188 Form CDC 57.207 Follow-up Laboratory Testing
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Modified 2500 417 16604 Form CDC 57.210 HCW Prophylaxis/Treatment-Influenza
57.300 Hemovigilance Module Annual Facility Survey Modified 500 1000 33140 Form CDC 57.300 Hemovigilance Module Annual Survey
57.301 Hemovigilance Module Monthly Reporting Plan Modified 6000 100 3314 Form CDC 57.301 Hemovigilance Module Monthly Reporting Plan
57.303 Hemovigilance Module Monthly Reporting Denominators Modified 6000 6000 198840 Form CDC 57.303 Hemovigilance Module Monthly Reporting Denominators
57.304 Hemovigilance Module Adverse Reaction Modified 24000 6000 198840 Form CDC 57.304 Hemovigilance Adverse Reaction
57.305 Hemovigilance Incident Modified 5000 833 27617 Form CDC 57.305 Hemovigilance Module Monthly Reporting Denominators
57.400 Outpatient Procedure - Annual Facility Survey Modified 5000 417 13117 Form CDC 57.400 Outpatient Procedure---Annual Facility Survey
57.401 Outpatient Procedure - Monthly Reporting Plan Modified 60000 15000 472200 Form CDC 57.401 Outpatient Procedure Component Monthly Reporting Plan
57.402 Outpatient Procedure - Event Modified 125000 83333 2623333 Form CDC 57.402 Outpatient Procedure - Event
57.403 Outpatient Procedure - Monthly Denominators and Summary Modified 60000 40000 1259200 Form CDC 57.403 Outpatient Procedure - Monthly Denominators and Summary
57.500 Outpatient Dialysis Center Practices Survey Modified 6500 11375 368940 Form and Instruction CDC 57.500 Outpatient Dialysis Center Practices Survey
57.501 Dialysis Monthly Reporting Plan Modified 78000 6500 204620 Form CDC 57.501 NHSN Registration Form
57.502 Dialysis Event Modified 390000 130000 2660060 Form CDC 57.502 Dialysis Event
57.503 Denominators for Outpatient Dialysis Modified 78000 7800 245544 Form and Instruction CDC 57.503 Denominators for Dialysis Event Surveillance (Census Form)
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Modified 18000 9000 283320 Form CDC 57-504 Prevention Process Measures Monthly Monitoring for Dialysis
57.505 Dialysis Patient Influenza Vaccination Modified 24375 4063 127888 Form CDC 57.505 Dialysis Patient Influenza Vaccination
57.506 Dialysis Patient Influenza Vaccination Denominator Modified 1625 271 8525 Form CDC 57.506 Dialysis Patient Influenza Vaccination Denominator
57.600 State Health Department Validation Record Modified 7600 1900 59622 Form CDC 57.600 State Health Department Validation Record
CDC 57.154 Antimicrobial Use & Resistance Component - Monthly Reporting Plan New 1200 100 0 Form CDC 57.154 Antimicrobial Use and Resistance Monthly Reporting Plan
Total burden requested under this ICR: 8975750 4277716 141057383  
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