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 5000 4583 94600 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)
57.113 Pediatric Ventilator-Associated Event (PedVAE) New 240000 100000 0 Form 57.113 Pediatric Ventilator-Associated Event (PedVAE)
57.114 Urinary Tract Infection (UTI) Modified 240000 80000 4389440 Form CDC 57.114 Urinary Tract infection (UTI)
57.115_CUS_BLANK New 182000 106167 0 Form 57.115 Custom Event
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 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) Modified 216000 126000 3950496 Form CDC 57.120 Surgical Site Infection (SSI)
57.121 Denominators for Procedure Modified 3240000 540000 8499600 Form CDC 57.121 Denominatoir 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 CDC 57.124 Antimicrobial Use and Resistance (AUR): Pharmacy Date Monthly Electronice Upload Specification Tables
57.125 Central Line Insertion Practices Adherence Monitoring Form Modified 100000 41667 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 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
57.129_Adult Sepsis_BLANK New 12500 5208 0 Form 57.129 Adult Sepsis_
57.137 Long Term care Facility Component--Annual Facility Survey Modified 350 378 9933 Form CDC 57.137 Long-Term Care Facility Component -- Annual Facility Survey
57.138 Laboratory-Identified MDRO or CDI Event for LTCF Modified 4200 1050 39732 Form CDC 57.138 Laboratory-identified MDRO or CDI Event for LTCF
57.139 MDRO and CDI LabID Event Reporting Monthly Summary Data for LTCF Modified 4200 700 13244 Form CDC 57.139 MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF
57.140 Urinary Tract Infection (UTI) for LTCF Modified 4900 2450 83437 Form CDC 57.140 Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF Modified 4200 350 13244 Form CDC 57.141 Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations Modified 4200 14070 476784 Form CDC 57.142 Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF Modified 3600 300 11352 Form CDC 57.143 Prevention Process Measures Monthly Monitoring
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Modified 400 367 7568 Form CDC 57.150 Patient Safety Component -- Annual Faciity Survey for LTAC
57.151 Patient Safety Component -- Annual Facility Survey for IRF Modified 1000 917 15767 Form CDC 57.151 Rehab Annual Survey
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 17000 1417 112918 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 Survey -- Acute Care Facility Modified 500 1000 33140 Form CDC 57.300 Hemovigilance Module - Annual Facility Survey -- Acute Care Facility
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 7020 198840 Form CDC 57.303 Hemovigilance Module Monthly Reporting Denominators
57.304 Hemovigilance Module Adverse Reaction Removed 0 0 0 Form CDC 57.304 Hemovigilance Module Adverse Reaction
57.305 Hemovigilance Incident Modified 5000 833 27617 Form CDC 57.305 Hemovigilance Module Incident
57.306_HV Annual Facility Sur New 200 117 0 Form 57.306 Hemovigilance Module Annual Survey - Non-acute Care Facility
57.307_HV AR-AHTR_BLANK New 2000 833 0 Form 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction
57.308_HV AR-Allergic_BLANK New 2000 833 0 Form 57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction
57.309_HV AR-DHTR_BLANK New 500 208 0 Form 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction
57.310_HV AR-DSTR_BLANK New 1000 417 0 Form 57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction
57.311_HV AR-FNHTR_BLANK New 2000 833 0 Form 57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction
57.312_HV AR-HTR_BLANK New 500 208 0 Form 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction
57.313_HV AR-Infection_BLAN New 500 208 0 Form 57.313 Hemovigilance Adverse Reaction - Infection
57.314_HV AR-PTP_BLAN New 500 208 0 Form 57.314 Hwemovilgilance Adverse Reaction - Post Transfusion Purpura
57.315_HV AR-TAD_BLAN New 500 208 0 Form 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea
57.316_HV AR-TAGVHD_BLAN New 500 208 0 Form 57.316 Hemovigilance Adverse Reaction - Transfusin Associated Graft vs. Host Disease
57.317_HV AR-TRALI_BLAN New 500 208 0 Form 57.317 Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury
57.318_HV AR-TACO_BLANK New 1000 417 0 Form 57.318 Hemoviligance Adverse Reaction - Transfusion Associated Circulatory Overload
57.319_HV AR-UNK_BLANK New 500 208 0 Form 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction
57.320_HV AR-Other_BLANK New 500 208 0 Form 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction
57.400 Outpatient Procedure - Annual Facility Survey Modified 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 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 13000 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 162500 2660060 Form CDC 57.502 Dialysis Event
57.503 Denominators for Outpatient Dialysis Modified 78000 13000 245544 Form CDC 57.503 Demominators for Dialysis Event Surveillance
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Modified 18000 22500 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
57.507_HomeDialysisSurv_BLA New 600 250 0 Form 57.507 Home Dialysis Center Practices Survey
Total burden requested under this ICR: 9440900 5110966 146700713  
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