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
57.101 Facility Contact Information Unchanged 2000 333 13220 Form CDC 57.101
57.103 Patient Safety Component - Annual Hospital Survey Modified 6000 7500 237960 Form CDC 57.103
57.105 Group Contact Information Unchanged 1000 83 3305 Form CDC 57.105
57.106 Patient Safety Monthly Reporting Plan Modified 72000 18000 713880 Form and Instruction CDC 57.106
57.108 Primary Bloodstream Infection (BSI) Modified 264000 145200 5235120 Form CDC 57.108
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Unchanged 129600 64800 2569968 Form CDC 57.111
57.112 Ventilator-Associated Event (VAE) Unchanged 864000 403200 15990912 Form CDC 57.112
57.113 Pediatric Ventilator-Associated Event (PedVAE) Modified 12000 6000 237960 Form CDC 57.113
57.114 Urinary Tract Infection (UTI) Modified 240000 80000 3172800 Form CDC 57.114
57.115_CUS_BLANK Unchanged 54600 31850 1263171 Form 57.115
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Modified 72000 288000 9345600 Form CDC 57.116
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Modified 18000 90600 2932200 Form CDC 57.117
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Unchanged 360000 1807200 58644000 Form CDC 57.118
57.120 Surgical Site Infection (SSI) Unchanged 216000 126000 4997160 Form CDC 57.120
57.121 Denominators for Procedure Modified 3240000 540000 17528400 Form CDC 57.121
57.122 HAI Progress Report State Health Department Survey New 55 41 0 Form CDC 55.122
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Modified 12000 1000 18730 Form CDC 57.123
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Modified 24000 2000 116808 Form CDC 57.124
57.125 Central Line Insertion Practices Adherence Monitoring Form Modified 10000 4167 165250 Form CDC 57.125
57.126 MDRO or CDI Infection Event Unchanged 432000 216000 8566560 Form CDC 57.126
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Modified 144000 36000 1427760 Form CDC 57.127
57.128 Laboratory Identified or CDI MDRO Event Unchanged 1440000 480000 19036800 Form CDC 57.128
Form and Instruction CDC 57.128 Rev 7, v8.5
57.129_Adult Sepsis_BLANK Unchanged 12500 5208 206562 Form 57.129
57.137 Long Term care Facility Component--Annual Facility Survey Unchanged 2600 5200 206232 Form CDC 57.137
57.138 Laboratory-Identified MDRO or CDI Event for LTCF Unchanged 31200 10400 412464 Form CDC 57.138
57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Modified 31200 10400 206232 Form CDC 57.139
57.140 Urinary Tract Infection (UTI) for LTCF Modified 36400 21233 842114 Form CDC 57.140
57.141 Monthly Reporting Plan for LTCF Unchanged 31200 2600 103116 Form CDC 57.141
57.142 Denominators for LTCF Locations Modified 31200 130000 4949568 Form CDC 57.142
57.143 Prevention Process Measures Monthly Monitoring for LTCF Unchanged 31200 2600 103116 Form CDC 57.143
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Modified 400 467 15864 Form CDC 57.150
57.151 Patient Safety Component -- Annual Facility Survey for IRF Modified 1000 1167 39660 Form CDC 57.151
57.200 Healthcare Personnel Safety Component Facility Survey Unchanged 50 400 13500 Form CDC 57.200
57.203 Healthcare Personnel Safety Reporting Plan Modified 19500 1625 54834 Form CDC 57.203
57.204 Healthcare Worker Demographic Data Unchanged 10000 3333 112500 Form CDC 57.204
57.205 Exposure to Blood and Body Fluids Unchanged 2500 2500 84375 Form CDC 57.205
57.206 Healthcare Worker Prophylaxis/Treatment Unchanged 1500 375 12655 Form CDC 57.206
57.207 Follow-up Laboratory Testing Unchanged 2500 625 11705 Form CDC 57.207
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Unchanged 2500 417 14063 Form CDC 57.210
57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Modified 500 708 34990 Form CDC 57.300
57.301 Hemovigilance Module Monthly Reporting Plan Unchanged 6000 100 3499 Form CDC 57.301
57.303 Hemovigilance Module Monthly Reporting Denominators Unchanged 6000 7020 245628 Form CDC 57.303
57.305 Hemovigilance Incident Unchanged 5000 833 29155 Form CDC 57.305
57.306_HV Annual Facility Sur Unchanged 200 117 4082 Form 57.306
57.307_HV AR-AHTR_BLANK Modified 2000 667 23326 Form 57.307
57.308_HV AR-Allergic_BLANK Modified 2000 667 23326 Form 57.308
57.309_HV AR-DHTR_BLANK Modified 500 167 5832 Form CDC 57.309
57.310_HV AR-DSTR_BLANK Modified 1000 333 11663 Form 57.310
57.311_HV AR-FNHTR_BLANK Modified 2000 667 23326 Form CDC 57.311
57.312_HV AR-HTR_BLANK Modified 500 167 5832 Form 57.312
57.313_HV AR-Infection_BLAN Modified 500 167 5832 Form 57.313
57.314_HV AR-PTP_BLAN Modified 500 167 5832 Form 57.314
57.315_HV AR-TAD_BLAN Modified 500 167 5832 Form CDC 57.315
57.316_HV AR-TAGVHD_BLAN Modified 500 167 5832 Form CDC 57.316
57.317_HV AR-TRALI_BLAN Modified 500 167 5832 Form 57.317
57.318_HV AR-TACO_BLANK Modified 1000 333 11663 Form 57.318
57.319_HV AR-UNK_BLANK Modified 500 167 5832 Form CDC 57.319
57.320_HV AR-Other_BLANK Unchanged 500 167 5832 Form 57.320
57.400 Outpatient Procedure - Annual Facility Survey Unchanged 5000 833 27050 Form CDC 57.400
57.401 Outpatient Procedure - Monthly Reporting Plan Unchanged 60000 20000 649002 Form CDC 57.401
57.402 Outpatient Procedure Component Event Unchanged 30000 20000 648990 Form CDC 57.402
57.403 Outpatient Procedure Component - Monthly Denominators and Summary Unchanged 14400 9600 311515 Form CDC 57.403
57.404 Outpatient Procedure Component - SSI Denominators Unchanged 2700000 450000 17820000 Form 57.404
57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Unchanged 180000 105000 4164300 Form 57.404
57.500 Outpatient Dialysis Center Practices Survey Modified 7000 14817 569100 Form CDC 57.500
57.501 Dialysis Monthly Reporting Plan Modified 84000 7000 227136 Form CDC 57.501
57.502 Dialysis Event Modified 420000 175000 5678820 Form CDC 57.502
57.503 Denominators for Outpatient Dialysis Unchanged 84000 14000 454440 Form CDC 57.503
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Modified 12000 17040 486744 Form CDC 57.504
57.505 Dialysis Patient Influenza Vaccination Modified 24375 4063 131820 Form CDC 57.505
57.506 Dialysis Patient Influenza Vaccination Denominator Unchanged 1625 271 8788 Form CDC 57.506
57.507_HomeDialysisSurv_BLA Unchanged 350 175 6940 Form 57.507
Total burden requested under this ICR: 11515655 5397438 191260525  
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