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 Unchanged 6765 6201 268300 Form CDC 57.103
57.104 NHSN Administrator Change Request Form Modified 800 67 0 Form and Instruction none
57.105 Group Contact Information Unchanged 1000 83 3305 Form CDC 57.105
57.106 Patient Safety Monthly Reporting Plan Unchanged 93852 23463 930543 Form and Instruction CDC 57.106
57.108 Primary Bloodstream Infection (BSI) Unchanged 28875 18288 572591 Form CDC 57.108
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Unchanged 3600 1800 71388 Form CDC 57.111
57.112 Ventilator-Associated Event (VAE) Unchanged 43704 20395 808874 Form CDC 57.112
57.113 Pediatric Ventilator-Associated Event (PedVAE) Unchanged 334 167 6623 Form CDC 57.113
57.114 Urinary Tract Infection (UTI) Unchanged 30000 10000 396600 Form CDC 57.114
57.115_CUS_BLANK Unchanged 54600 31850 1263171 Form CDC 57.115
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Unchanged 13200 880 1713360 Form CDC 57.116
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Unchanged 6000 500 977400 Form CDC 57.117
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Unchanged 330000 27500 53757000 Form CDC 57.118
57.120 Surgical Site Infection (SSI) Unchanged 54000 31500 1249290 Form CDC 57.120
57.121 Denominators for Procedure Unchanged 3612000 602000 19540920 Form CDC 57.121
57.122 HAI Progress Report State Health Department Survey Unchanged 55 26 0 Form CDC 55.122
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Unchanged 30000 2500 46824 Form CDC 57.123
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Unchanged 30000 2500 146010 Form CDC 57.124
Form 0920-0666 CDC 57.124
57.125 Central Line Insertion Practices Adherence Monitoring Form Unchanged 106500 44375 1759912 Form CDC 57.125
57.126 MDRO or CDI Infection Event Unchanged 7920 3960 157054 Form CDC 57.126
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Unchanged 159500 39875 1581442 Form CDC 57.127
57.128 Laboratory Identified or CDI MDRO Event Unchanged 379200 126400 5013024 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
57.135 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) Unchanged 1800 150 0 Form and Instruction 57.135
57.136 Long Term Care Facility Component - Respiratory Tract Infection Unchanged 1800 150 0 Form and Instruction 57.136
57.137 Long Term care Facility Component--Annual Facility Survey Unchanged 3079 51 244226 Form CDC 57.137
57.138 Laboratory-Identified MDRO or CDI Event for LTCF Unchanged 47952 9590 633925 Form CDC 57.138
57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Unchanged 23976 7992 158481 Form CDC 57.139
57.140 Urinary Tract Infection (UTI) for LTCF Unchanged 12204 7119 282340 Form CDC 57.140
57.141 Monthly Reporting Plan for LTCF Unchanged 24132 2011 79756 Form CDC 57.141
57.142 Denominators for LTCF Locations Unchanged 4068 2373 645348 Form CDC 57.142
57.143 Prevention Process Measures Monthly Monitoring for LTCF Unchanged 1560 312 5156 Form CDC 57.143
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Unchanged 620 103 24589 Form CDC 57.150
57.151 Patient Safety Component -- Annual Facility Survey for IRF Unchanged 1340 223 53144 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 Unchanged 19500 0 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 Unchanged 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 7000 245628 Form CDC 57.303
57.305 Hemovigilance Incident Unchanged 5000 833 29155 Form CDC 57.305
57.306_HV Annual Facility Sur Unchanged 500 292 10205 Form 57.306
57.307_HV AR-AHTR_BLANK Unchanged 2000 667 23326 Form 57.307
57.308_HV AR-Allergic_BLANK Unchanged 2000 667 23326 Form 57.308
57.309_HV AR-DHTR_BLANK Unchanged 500 167 5832 Form CDC 57.309
57.310_HV AR-DSTR_BLANK Unchanged 1000 333 11663 Form 57.310
57.311_HV AR-FNHTR_BLANK Unchanged 2000 667 23326 Form CDC 57.311
57.312_HV AR-HTR_BLANK Unchanged 500 167 5832 Form 57.312
57.313_HV AR-Infection_BLAN Unchanged 500 167 5832 Form 57.313
57.314_HV AR-PTP_BLAN Unchanged 500 167 5832 Form 57.314
57.315_HV AR-TAD_BLAN Unchanged 500 167 5832 Form CDC 57.315
57.316_HV AR-TAGVHD_BLAN Unchanged 500 167 5832 Form CDC 57.316
57.317_HV AR-TRALI_BLAN Unchanged 500 167 5832 Form 57.317
57.318_HV AR-TACO_BLANK Unchanged 1000 333 11663 Form 57.318
57.319_HV AR-UNK_BLANK Unchanged 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 700 117 3787 Form CDC 57.400
57.401 Outpatient Procedure - Monthly Reporting Plan Unchanged 8400 2100 90860 Form CDC 57.401
57.402 Outpatient Procedure Component Event Unchanged 200 133 4327 Form CDC 57.402
57.403 Outpatient Procedure Component - Monthly Denominators and Summary Unchanged 80000 53333 1730640 Form CDC 57.403
57.404 Outpatient Procedure Component - SSI Denominators Unchanged 70000 46667 462000 Form 57.404
57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Unchanged 3500 2333 80973 Form 57.404
57.500 Outpatient Dialysis Center Practices Survey Unchanged 7200 1440 585360 Form CDC 57.500
57.501 Dialysis Monthly Reporting Plan Unchanged 86400 7200 233626 Form CDC 57.501
57.502 Dialysis Event Unchanged 216000 90000 2920536 Form CDC 57.502
57.503 Denominators for Outpatient Dialysis Unchanged 216000 36000 1168560 Form CDC 57.503
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Unchanged 20760 25950 842067 Form CDC 57.504
57.505 Dialysis Patient Influenza Vaccination Unchanged 30750 5125 166296 Form CDC 57.505
57.506 Dialysis Patient Influenza Vaccination Denominator Unchanged 3075 513 16630 Form CDC 57.506
57.507_HomeDialysisSurv_BLA Unchanged 430 215 8527 Form 57.507
Total burden requested under this ICR: 5943401 1321991 101704078  
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