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 5175 6469 205240 Form CDC 57.103 Annual Hospital Survey - Patient Safety Component
57.104 NHSN Administrator Change Request Form New 800 67 0 Form and Instruction 57.104 FAChangeRequest_BLANK
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) Modified 28875 18288 572591 Form CDC 57.108 Primary Bloodstream Infection
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Modified 54000 27000 1070820 Form CDC 57.111 Pneumonia (PNEU)
57.112 Ventilator-Associated Event (VAE) Modified 28075 12833 519612 Form CDC 57.112 Ventilator-Associated Event (VAE)
57.113 Pediatric Ventilator-Associated Event (PedVAE) Modified 40080 20040 794786 Form CDC 57.113 Pediatric Ventilator-Associated Event (VAE)
57.114 Urinary Tract Infection (UTI) Modified 27500 9167 363550 Form CDC 57.114 Urinary Tract infection (UTI)
57.115_CUS_BLANK Modified 54600 31850 1263171 Form 57.115 Custom Event
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Modified 2640 11616 342672 Form CDC 57.116 PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Modified 1980 10395 322542 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 330000 1732500 53757000 Form CDC 57.118 Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
57.120 Surgical Site Infection (SSI) Modified 49500 28875 1145183 Form CDC 57.120 Surgical Site Infection (SSI)
57.121 Denominators for Procedure Modified 3060000 510000 16554600 Form CDC 57.121 Denominatoir for Procedure
57.122 HAI Progress Report State Health Department Survey Modified 55 41 0 Form CDC 55.122 State Health Department HAI Mandate and Validatyion Survey
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Modified 18000 1500 28094 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 24000 2000 116808 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 106500 44375 1759912 Form CDC 57.125 Central Line Insertion Practices Adherence Monitoring
57.126 MDRO or CDI Infection Event Modified 8640 4320 171331 Form CDC 57.126 MDRO or CDI Infection Event
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Modified 159500 39875 1581442 Form CDC 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting
57.128 Laboratory Identified or CDI MDRO Event Modified 417600 139200 5520672 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_
57.136 Long Term Care Facility Component - Respiratory Tract Infection New 4800 2400 0 Form and Instruction 57.136 Long-Term Care Facility Component – Respiratory Tract Infection
57.137 Long Term care Facility Component--Annual Facility Survey Modified 2200 4400 174504 Form CDC 57.137 Long-Term Care Facility Component -- Annual Facility Survey
57.138 Laboratory-Identified MDRO or CDI Event for LTCF Modified 51600 12900 682152 Form CDC 57.138 Laboratory-identified MDRO or CDI Event for LTCF
57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Modified 26400 8800 174504 Form CDC 57.139 MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF
57.140 Urinary Tract Infection (UTI) for LTCF Modified 4800 2400 111048 Form CDC 57.140 Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF Modified 26640 2220 88045 Form CDC 57.141 Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations Modified 26640 117216 4226170 Form CDC 57.142 Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF Modified 4500 375 14873 Form CDC 57.143 Prevention Process Measures Monthly Monitoring
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Modified 500 625 19830 Form CDC 57.150 Patient Safety Component - Annual Facility Survey for LTAC
57.151 Patient Safety Component -- Annual Facility Survey for IRF Modified 1200 1500 47592 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 Modified 19500 0 54834 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 500 708 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 CDC 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 CDC 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 CDC 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea
57.316_HV AR-TAGVHD_BLAN Unchanged 500 167 5832 Form CDC 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 CDC 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 Modified 700 117 3787 Form CDC 57.400 Outpatient Procedure Component - Annual Facility Survey
57.401 Outpatient Procedure - Monthly Reporting Plan Modified 8400 2100 90860 Form CDC 57.401 Outpatient Procedure Component - Monthly Reporting Plan
57.402 Outpatient Procedure Component Event Modified 200 133 4327 Form CDC 57.402 Outpatient Procedure - Event
57.403 Outpatient Procedure Component - Monthly Denominators and Summary Modified 80000 53333 1730640 Form CDC 57.403 Outpatient Procedure - Monthly Denominators and Summary
57.404 Outpatient Procedure Component - SSI Denominators Modified 70000 46667 462000 Form 57.404 Outpatient Procedure Component - SSI Denominators
57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Modified 3500 2333 80973 Form 57.404 Outpatient Procedure Component - SSI Denominators
57.500 Outpatient Dialysis Center Practices Survey Modified 7100 15975 577230 Form CDC 57.500 Outpatient Dialysis Center Practices Survey
57.501 Dialysis Monthly Reporting Plan Modified 85200 7100 230381 Form CDC 57.501 NHSN Registration Form
57.502 Dialysis Event Modified 213000 88750 2879973 Form CDC 57.502 Dialysis Event
57.503 Denominators for Outpatient Dialysis Modified 85200 14200 460932 Form CDC 57.503 Demominators for Dialysis Event Surveillance
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Modified 21120 26400 856669 Form CDC 57.504 Prevention Process Measures Monthly Monitoring for Dialysis
57.505 Dialysis Patient Influenza Vaccination Modified 51600 8600 279053 Form CDC 57.505 Dialysis Patient Influenza Vaccination
57.506 Dialysis Patient Influenza Vaccination Denominator Modified 860 72 4651 Form CDC 57.506 Dialysis Patient Influenza Vaccination Denominator
57.507_HomeDialysisSurv_BLA Modified 430 215 8527 Form 57.507 Home Dialysis Center Practices Survey
Total burden requested under this ICR: 5352360 3113631 101009102  
To view an IC, click on IC Title