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Agenda
Reg Review
ICR
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
Unchanged
6765
6201
268300
Form
CDC 57.103
Annual Hospital Survey - Patient Safety Component
57.104 NHSN Administrator Change Request Form
Modified
800
67
0
Form and Instruction
none
Facility Administrator Change Request
57.105 Group Contact Information
Unchanged
1000
83
3305
Form
CDC 57.105
Group Contact Information
57.106 Patient Safety Monthly Reporting Plan
Unchanged
93852
23463
930543
Form and Instruction
CDC 57.106
Patient Safety Monthly Reporting Plan
57.108 Primary Bloodstream Infection (BSI)
Unchanged
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)
Unchanged
3600
1800
71388
Form
CDC 57.111
Pneumonia
57.112 Ventilator-Associated Event (VAE)
Unchanged
43704
20395
808874
Form
CDC 57.112
Ventilator-associated event
57.113 Pediatric Ventilator-Associated Event (PedVAE)
Unchanged
334
167
6623
Form
CDC 57.113
Pediatric Ventilator-associated Event
57.114 Urinary Tract Infection (UTI)
Unchanged
30000
10000
396600
Form
CDC 57.114
Urinary tract infection
57.115_CUS_BLANK
Unchanged
54600
31850
1263171
Form
CDC 57.115
Custom Event
57.116 Denominators for Neonatal Intensive Care Unit (NICU)
Unchanged
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)
Unchanged
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)
Unchanged
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)
Unchanged
54000
31500
1249290
Form
CDC 57.120
Surgical site infection
57.121 Denominators for Procedure
Unchanged
3612000
602000
19540920
Form
CDC 57.121
Denominatoir for Procedure
57.122 HAI Progress Report State Health Department Survey
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
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)
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
12204
7119
282340
Form
CDC 57.140
Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF
Unchanged
24132
2011
79756
Form
CDC 57.141
Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations
Unchanged
4068
2373
645348
Form
CDC 57.142
Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF
Unchanged
1560
312
5156
Form
CDC 57.143
Prevention Process Measures Monthly Monitoring
57.150 Patient Safety Component -- Annual Facility Survey for LTAC
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
7200
1440
585360
Form
CDC 57.500
Outpatient Dialysis Center Practices Survey
57.501 Dialysis Monthly Reporting Plan
Unchanged
86400
7200
233626
Form
CDC 57.501
NHSN Registration Form
57.502 Dialysis Event
Unchanged
216000
90000
2920536
Form
CDC 57.502
Dialysis Event
57.503 Denominators for Outpatient Dialysis
Unchanged
216000
36000
1168560
Form
CDC 57.503
Demominators for Dialysis Event Surveillance
57.504 Prevention Process Measures Monthly Monitoring for Dialysis
Unchanged
20760
25950
842067
Form
CDC 57.504
Prevention Process Measures Monthly Monitoring for Dialysis
57.505 Dialysis Patient Influenza Vaccination
Unchanged
30750
5125
166296
Form
CDC 57.505
Dialysis Patient Influenza Vaccination
57.506 Dialysis Patient Influenza Vaccination Denominator
Unchanged
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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