Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
57.100 NHSN Registration Form Unchanged 2000 167 6307 Form CDC 57.100 NHSN Registration Form
57.101 Facility Contact Information Unchanged 2000 333 12613 Form CDC 57.101 Facility Contact Information
57.103 Patient Safety Component - Annual Hospital Survey Unchanged 5000 4167 94600 Form CDC 57.103 Patient Safety Component-Annual Hospital Survey
57.105 Group Contact Information Unchanged 1000 83 3153 Form CDC 57.105 Group Contact Information
57.106 Patient Safety Monthly Reporting Plan Unchanged 72000 18000 1589280 Form and Instruction CDC 57.106 Patient Safety Monthly Reporting Plan
57.108 Primary Bloodstream Infection (BSI) Unchanged 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) Unchanged 432000 216000 7900992 Form CDC 57.111 Pneumonia (PNEU)
57.112 Ventilator-Associated Event (VAE) Unchanged 864000 360000 11987712 Form CDC 57.112 Ventilator-Associated Event (VAE)
57.114 Urinary Tract Infection (UTI) Unchanged 240000 80000 4389440 Form CDC 57.114 Urinary Tract infection (UTI)
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Unchanged 54000 162000 5099760 Form CDC 57.116 Denominators for Neonatal intensive Care Unit (NICU)
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Unchanged 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) Unchanged 360000 1800000 56664000 Form CDC 57.118 Denominators for Intensive Care Unit (ICU)/Other Locations (Not NICU or SCA)
57.120 Surgical Site Infection (SSI) Unchanged 216000 126000 3950496 Form CDC 57.120 Surgical Site Infection (SSI)
57.121 Denominators for Procedure Unchanged 3240000 270000 8499600 Form CDC 57.121 Denominatoir for Procedure
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Unchanged 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 Unchanged 72000 6000 84600 Form CDC 57.124 Antimicrobial Use and Resistance (AUR): Pharmacy Date Monthly Electronice Upload Specification Tables
57.125 Central Line Insertion Practices Adherence Monitoring Form Unchanged 100000 41667 315333 Form CDC 57.125 Central Line Insertion Practices Adherence Monitoring
57.126 MDRO or CDI Infection Event Unchanged 432000 216000 7900992 Form CDC 57.126 MDRO or CDI Infection Event
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Unchanged 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 Unchanged 1440000 480000 13622400 Form CDC 57.128 Laboratory-identified MDRO or CDI Event
Form and Instruction CDC 57.128 Rev 7, v8.5 Lab ID Event
57.137 Long Term care Facility Component--Annual Facility Survey Unchanged 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 Unchanged 2000 500 18920 Form CDC 57.138 Laboratory-identified MDRO or CDI Event for LTCF
57.139 MDRO and CDI Monthly Monitoring for LTCF Unchanged 3000 250 9460 Form CDC 57.139 MDRO and CDI Monthly Monitoring for LTCF
57.140 Urinary Tract Infection (UTI) for LTCF Unchanged 2250 1125 38313 Form CDC 57.140 Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF Unchanged 3000 250 9460 Form CDC 57.141 Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations Unchanged 3000 9750 340560 Form CDC 57.142 Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF Unchanged 3000 250 9460 Form CDC 57.143 Prevention Process Measures Monthly Monitoring
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Unchanged 400 333 7568 Form CDC 57.150 Patient Safety Component -- Annual Faciity Survey for LTAC
57.151 Patient Safety Component -- Annual Facility Survey for IRF Unchanged 1000 833 15767 Form CDC 57.151 Patient Safetu Component--Annual Faciluity Survey for IRF
57.200 Healthcare Personnel Safety Component Facility Survey Unchanged 50 400 15940 Form CDC 57.200 Healthcare Personnel Safety - Annual Facility Survey
57.203 Healthcare Personnel Safety Reporting Plan Unchanged 17000 1417 112918 Form CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan
57.204 Healthcare Worker Demographic Data Unchanged 10000 3333 132833 Form CDC 57.204 Healthcare Worker Demographic Data
57.205 Exposure to Blood and Body Fluids Unchanged 2500 2500 99625 Form CDC 57.205 Exposure to Blood/Body Fluids
57.206 Healthcare Worker Prophylaxis/Treatment Unchanged 1500 375 14944 Form CDC 57.206 Healthcare Worker Prophylaxis/Treatment
57.207 Follow-up Laboratory Testing Unchanged 2500 625 11188 Form CDC 57.207 Follow-up Laboratory Testing
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Unchanged 2500 417 16604 Form CDC 57.210 HCW Prophylaxis/Treatment-Influenza
57.300 Hemovigilance Module Annual Facility Survey Unchanged 500 1000 33140 Form CDC 57.300 Hemovigilance Module--Annual Facility Survey
57.301 Hemovigilance Module Monthly Reporting Plan Unchanged 6000 100 3314 Form CDC 57.301 Hemovigilance Module Monthly Reporting Plan
57.303 Hemovigilance Module Monthly Reporting Denominators Modified 6000 7000 198840 Form CDC 57.303 Hemovigilance Module Monthly Reporting Denominators
57.304 Hemovigilance Module Adverse Reaction Unchanged 24000 6000 198840 Form CDC 57.304 Hemovigilance Module Adverse Reaction
57.305 Hemovigilance Incident Unchanged 5000 833 27617 Form CDC 57.305 Hemovigilance Module Incident
57.400 Outpatient Procedure - Annual Facility Survey Unchanged 5000 417 13117 Form CDC 57.400 Patient Safety Component---Annual Facility Survey for Ambulatory Surgery Center (ASC)
57.401 Outpatient Procedure - Monthly Reporting Plan Unchanged 60000 15000 472200 Form CDC 57.401 Outpatient Procedure Component Monthly Reporting Plan
57.402 Outpatient Procedure - Event Unchanged 125000 83333 2623333 Form CDC 57.402 Outpatient Procedure - Event
57.403 Outpatient Procedure - Monthly Denominators and Summary Unchanged 60000 40000 1259200 Form CDC 57.403 Outpatient Procedure - Monthly Denominators and Summary
57.500 Outpatient Dialysis Center Practices Survey Unchanged 6500 13000 368940 Form and Instruction CDC 57.500 Outpatient Dialysis Center Practices Survey
57.501 Dialysis Monthly Reporting Plan Unchanged 78000 6500 204620 Form CDC 57.501 NHSN Registration Form
57.502 Dialysis Event Unchanged 390000 162500 2660060 Form CDC 57.502 Dialysis Event
57.503 Denominators for Outpatient Dialysis Unchanged 78000 13000 245544 Form CDC 57.503 Demominators for Dialysis Event Surveillance
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Unchanged 18000 22500 283320 Form CDC 57.504 Prevention Process Measures Monthly Monitoring for Dialysis
57.505 Dialysis Patient Influenza Vaccination Unchanged 24375 4063 127888 Form CDC 57.505 Dialysis Patient Influenza Vaccination
57.506 Dialysis Patient Influenza Vaccination Denominator Unchanged 1625 271 8525 Form CDC 57.506 Dialysis Patient Influenza Vaccination Denominator
Total burden requested under this ICR: 9007950 4622542 146685095  
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