Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
57.100 NHSN Registration Form Unchanged 2000 167 6610 Form CDC 57.100 NHSN Registration Form
57.101 Facility Contact Information Unchanged 2000 333 13220 Form CDC 57.101 Facility Contact Information
57.103 Patient Safety Component - Annual Hospital Survey Modified 5000 5000 198300 Form CDC 57.103 Annual Hospital Survey - Patient Safety Component
57.105 Group Contact Information Unchanged 1000 83 3305 Form CDC 57.105 Group Contact Information
57.106 Patient Safety Monthly Reporting Plan Unchanged 72000 18000 713880 Form and Instruction CDC 57.106 Patient Safety Monthly Reporting Plan
57.108 Primary Bloodstream Infection (BSI) Unchanged 264000 145200 5235120 Form CDC 57.108 Primary Bloodstream Infection
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Unchanged 129600 64800 2569968 Form CDC 57.111 Pneumonia (PNEU)
57.112 Ventilator-Associated Event (VAE) Unchanged 864000 403200 15990912 Form CDC 57.112 Ventilator-Associated Event (VAE)
57.113 Pediatric Ventilator-Associated Event (PedVAE) Unchanged 12000 6000 237960 Form CDC 57.113 Pediatric Ventilator-Associated Event (VAE)
57.114 Urinary Tract Infection (UTI) Unchanged 240000 80000 3172800 Form CDC 57.114 Urinary Tract infection (UTI)
57.115_CUS_BLANK Unchanged 54600 31850 1263171 Form 57.115 Custom Event
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Unchanged 72000 216000 9345600 Form CDC 57.116 PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Unchanged 54000 271080 8796600 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 1807200 58644000 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 4997160 Form CDC 57.120 Surgical Site Infection (SSI)
57.121 Denominators for Procedure Unchanged 3240000 540000 17528400 Form CDC 57.121 Denominatoir for Procedure
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Unchanged 4200 350 6555 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 9600 800 46723 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 10000 4167 165250 Form CDC 57.125 Central Line Insertion Practices Adherence Monitoring
57.126 MDRO or CDI Infection Event Modified 432000 216000 8566560 Form CDC 57.126 MDRO or CDI Infection Event
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Unchanged 144000 36000 1427760 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 19036800 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 Unchanged 12500 5208 206562 Form 57.129 Adult Sepsis_
57.137 Long Term care Facility Component--Annual Facility Survey Unchanged 2600 5200 206232 Form CDC 57.137 Long-Term Care Facility Component -- Annual Facility Survey
57.138 Laboratory-Identified MDRO or CDI Event for LTCF Unchanged 31200 10400 412464 Form CDC 57.138 Laboratory-identified MDRO or CDI Event for LTCF
57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Unchanged 31200 5200 206232 Form CDC 57.139 MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF
57.140 Urinary Tract Infection (UTI) for LTCF Unchanged 36400 21233 842114 Form CDC 57.140 Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF Unchanged 31200 2600 103116 Form CDC 57.141 Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations Unchanged 31200 124800 4949568 Form CDC 57.142 Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF Unchanged 31200 2600 103116 Form CDC 57.143 Prevention Process Measures Monthly Monitoring
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Modified 400 400 15864 Form CDC 57.150 Patient Safety Component - Annual Facility Survey for LTAC
57.151 Patient Safety Component -- Annual Facility Survey for IRF Modified 1000 1000 39660 Form CDC 57.151 Patient Safety Component - Annual Facility Survey for IRF
57.200 Healthcare Personnel Safety Component Facility Survey Unchanged 50 400 13500 Form CDC 57.200 Healthcare Personnel Safety - Annual Facility Survey
57.203 Healthcare Personnel Safety Reporting Plan Unchanged 17000 1417 47804 Form CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan
57.204 Healthcare Worker Demographic Data Unchanged 10000 3333 112500 Form CDC 57.204 Healthcare Worker Demographic Data
57.205 Exposure to Blood and Body Fluids Unchanged 2500 2500 84375 Form CDC 57.205 Exposure to Blood/Body Fluids
57.206 Healthcare Worker Prophylaxis/Treatment Unchanged 1500 375 12655 Form CDC 57.206 Healthcare Worker Prophylaxis/Treatment
57.207 Follow-up Laboratory Testing Unchanged 2500 625 11705 Form CDC 57.207 Follow-up Laboratory Testing
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Unchanged 2500 417 14063 Form CDC 57.210 HCW Prophylaxis/Treatment-Influenza
57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Unchanged 500 1000 34990 Form CDC 57.300 Hemovigilance Module - Annual Survey
57.301 Hemovigilance Module Monthly Reporting Plan Unchanged 6000 100 3499 Form CDC 57.301 Hemovigilance Module Monthly Reporting Plan
57.303 Hemovigilance Module Monthly Reporting Denominators Unchanged 6000 7020 245628 Form CDC 57.303 Hemovigilance Module Monthly Reporting Denominators
57.305 Hemovigilance Incident Unchanged 5000 833 29155 Form CDC 57.305 Hemovigilance Module Incident
57.306_HV Annual Facility Sur Unchanged 200 117 4082 Form 57.306 Hemovigilance Module Annual Survey - Non-acute Care Facility
57.307_HV AR-AHTR_BLANK Unchanged 2000 667 23326 Form 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction
57.308_HV AR-Allergic_BLANK Unchanged 2000 667 23326 Form 57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction
57.309_HV AR-DHTR_BLANK Unchanged 500 167 5832 Form 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction
57.310_HV AR-DSTR_BLANK Unchanged 1000 333 11663 Form 57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction
57.311_HV AR-FNHTR_BLANK Unchanged 2000 667 23326 Form 57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction
57.312_HV AR-HTR_BLANK Unchanged 500 167 5832 Form 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction
57.313_HV AR-Infection_BLAN Unchanged 500 167 5832 Form 57.313 Hemovigilance Adverse Reaction - Infection
57.314_HV AR-PTP_BLAN Unchanged 500 167 5832 Form 57.314 Hwemovilgilance Adverse Reaction - Post Transfusion Purpura
57.315_HV AR-TAD_BLAN Unchanged 500 167 5832 Form 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea
57.316_HV AR-TAGVHD_BLAN Unchanged 500 167 5832 Form 57.316 Hemovigilance Adverse Reaction - Transfusin Associated Graft vs. Host Disease
57.317_HV AR-TRALI_BLAN Unchanged 500 167 5832 Form 57.317 Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury
57.318_HV AR-TACO_BLANK Unchanged 1000 333 11663 Form 57.318 Hemoviligance Adverse Reaction - Transfusion Associated Circulatory Overload
57.319_HV AR-UNK_BLANK Unchanged 500 167 5832 Form 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction
57.320_HV AR-Other_BLANK Unchanged 500 167 5832 Form 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction
57.400 Outpatient Procedure - Annual Facility Survey Unchanged 5000 833 27050 Form CDC 57.400 Outpatient Procedure Component - Annual Facility Survey
57.401 Outpatient Procedure - Monthly Reporting Plan Unchanged 60000 20000 649002 Form CDC 57.401 Outpatient Procedure Component - Monthly Reporting Plan
57.402 Outpatient Procedure Component Event Unchanged 30000 20000 648990 Form CDC 57.402 Outpatient Procedure - Event
57.403 Outpatient Procedure Component - Monthly Denominators and Summary Unchanged 14400 9600 311515 Form CDC 57.403 Outpatient Procedure - Monthly Denominators and Summary
57.404 Outpatient Procedure Component - SSI Denominators Unchanged 2700000 450000 17820000 Form 57.404 Outpatient Procedure Component - SSI Denominators
57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Unchanged 180000 105000 4164300 Form 57.404 Outpatient Procedure Component - SSI Denominators
57.500 Outpatient Dialysis Center Practices Survey Modified 7000 14350 569100 Form CDC 57.500 Outpatient Dialysis Center Practices Survey
57.501 Dialysis Monthly Reporting Plan Unchanged 84000 7000 227136 Form CDC 57.501 NHSN Registration Form
57.502 Dialysis Event Unchanged 420000 175000 5678820 Form CDC 57.502 Dialysis Event
57.503 Denominators for Outpatient Dialysis Unchanged 84000 14000 454440 Form CDC 57.503 Demominators for Dialysis Event Surveillance
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Unchanged 24000 30000 973488 Form CDC 57.504 Prevention Process Measures Monthly Monitoring for Dialysis
57.505 Dialysis Patient Influenza Vaccination Unchanged 24375 4063 131820 Form CDC 57.505 Dialysis Patient Influenza Vaccination
57.506 Dialysis Patient Influenza Vaccination Denominator Unchanged 1625 271 8788 Form CDC 57.506 Dialysis Patient Influenza Vaccination Denominator
57.507_HomeDialysisSurv_BLA Unchanged 350 175 6940 Form 57.507 Home Dialysis Center Practices Survey
Total burden requested under this ICR: 11537900 5503470 197482719  
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