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 6765 6201 268300 Form CDC 57.103 Annual Hospital Survey - Patient Safety Component
57.104 NHSN Administrator Change Request Form Unchanged 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 Modified 93852 23463 930543 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 blood stream infection
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Modified 3600 1800 71388 Form CDC 57.111 Pneumonia
57.112 Ventilator-Associated Event (VAE) Modified 43704 20395 808874 Form CDC 57.112 Ventilator-associated event
57.113 Pediatric Ventilator-Associated Event (PedVAE) Modified 334 167 6623 Form CDC 57.113 Pediatric Ventilator-associated Event
57.114 Urinary Tract Infection (UTI) Modified 30000 10000 396600 Form CDC 57.114 Urinary tract infection
57.115_CUS_BLANK Modified 54600 31850 1263171 Form CDC 57.115 Custom Event
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Modified 13200 880 1713360 Form CDC 57.116 PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Modified 6000 500 977400 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 27500 53757000 Form CDC 57.118 Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
57.120 Surgical Site Infection (SSI) Modified 54000 31500 1249290 Form CDC 57.120 Surgical site infection
57.121 Denominators for Procedure Modified 3612000 602000 19540920 Form CDC 57.121 Denominatoir for Procedure
57.122 HAI Progress Report State Health Department Survey Modified 55 26 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 30000 2500 46824 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 30000 2500 146010 Form CDC 57.124 Antimicrobial Use and Resistance (AUR): Pharmacy Date Monthly Electronice Upload Specification Tables
Form 0920-0666 CDC 57.124 AUR - Pharmacy Electronic Upload - Remdesivir
57.125 Central Line Insertion Practices Adherence Monitoring Form Unchanged 106500 44375 1759912 Form CDC 57.125 Central Line Insertion Practices Adherence Monitoring
57.126 MDRO or CDI Infection Event Modified 7920 3960 157054 Form CDC 57.126 MDRO or CDI Infection Event
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Unchanged 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 379200 126400 5013024 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_
57.135 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) New 1800 150 0 Form and Instruction 57.135 57.135 Late Onset Sepsis/ Meningitis Denominator Form: Data Table for monthly electronic upload
57.136 Long Term Care Facility Component - Respiratory Tract Infection Modified 1800 150 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 3079 51 244226 Form CDC 57.137 Long-Term Care Facility Component -- Annual Facility Survey
57.138 Laboratory-Identified MDRO or CDI Event for LTCF Modified 47952 9590 633925 Form CDC 57.138 Laboratory-identified MDRO or CDI Event for LTCF
57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Modified 23976 7992 158481 Form CDC 57.139 MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF
57.140 Urinary Tract Infection (UTI) for LTCF Modified 12204 7119 282340 Form CDC 57.140 Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF Modified 24132 2011 79756 Form CDC 57.141 Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations Modified 4068 2373 645348 Form CDC 57.142 Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF Modified 1560 312 5156 Form CDC 57.143 Prevention Process Measures Monthly Monitoring
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Modified 620 103 24589 Form CDC 57.150 Patient Safety Component - Annual Facility Survey for LTAC
57.151 Patient Safety Component -- Annual Facility Survey for IRF Modified 1340 223 53144 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 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 Modified 6000 7000 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 Modified 500 292 10205 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 Unchanged 700 117 3787 Form CDC 57.400 Outpatient Procedure Component - Annual Facility Survey
57.401 Outpatient Procedure - Monthly Reporting Plan Unchanged 8400 2100 90860 Form CDC 57.401 Outpatient Procedure Component - Monthly Reporting Plan
57.402 Outpatient Procedure Component Event Unchanged 200 133 4327 Form CDC 57.402 Outpatient Procedure - Event
57.403 Outpatient Procedure Component - Monthly Denominators and Summary Unchanged 80000 53333 1730640 Form CDC 57.403 Outpatient Procedure - Monthly Denominators and Summary
57.404 Outpatient Procedure Component - SSI Denominators Unchanged 70000 46667 462000 Form 57.404 Outpatient Procedure Component - SSI Denominators
57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Unchanged 3500 2333 80973 Form 57.404 Outpatient Procedure Component - SSI Denominators
57.500 Outpatient Dialysis Center Practices Survey Modified 7200 1440 585360 Form CDC 57.500 Outpatient Dialysis Center Practices Survey
57.501 Dialysis Monthly Reporting Plan Modified 86400 7200 233626 Form CDC 57.501 NHSN Registration Form
57.502 Dialysis Event Modified 216000 90000 2920536 Form CDC 57.502 Dialysis Event
57.503 Denominators for Outpatient Dialysis Modified 216000 36000 1168560 Form CDC 57.503 Demominators for Dialysis Event Surveillance
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Modified 20760 25950 842067 Form CDC 57.504 Prevention Process Measures Monthly Monitoring for Dialysis
57.505 Dialysis Patient Influenza Vaccination Modified 30750 5125 166296 Form CDC 57.505 Dialysis Patient Influenza Vaccination
57.506 Dialysis Patient Influenza Vaccination Denominator Modified 3075 513 16630 Form CDC 57.506 Dialysis Patient Influenza Vaccination Denominator
57.507_HomeDialysisSurv_BLA Unchanged 430 215 8527 Form 57.507 Home Dialysis Center Practices Survey
Total burden requested under this ICR: 5943401 1321991 101704078  
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