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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
Modified
2000
167
0
Form
CDC 57.100
NHSN Registration Form
57.101 Facility Contact Information
Modified
2000
333
0
Form
CDC 57.101
Facility Contact Information
57.103 Patient Safety Component - Annual Hospital Survey
Modified
6765
10148
0
Form and Instruction
None
Patient Safety Component-Annual Hospital Survey (changes for 2023)
57.104 NHSN Administrator Change Request Form
Unchanged
800
67
0
Form and Instruction
none
Facility Administrator Change Request
57.105 Group Contact Information
Modified
1000
83
0
Form
CDC 57.105
Group Contact Information
57.106 Patient Safety Monthly Reporting Plan
Modified
93852
23463
0
Form and Instruction
57.106
Patient Safety Monthly Reporting Plan
57.108 Primary Bloodstream Infection (BSI)
Modified
28875
18769
0
Form and Instruction
57.108
Primary Bloodstream Infection (BSI)
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)
Modified
3600
1860
0
Form and Instruction
57.111
Pneumonia (PNEU)
57.112 Ventilator-Associated Event (VAE)
Modified
43704
21124
0
Form and Instruction
57.112
Ventilator Associated Event (VAE)
57.113 Pediatric Ventilator-Associated Event (PedVAE)
Modified
334
173
0
Form and Instruction
57.113
Pediatric Ventilator-Associated Event (PedVAE)
57.114 Urinary Tract Infection (UTI)
Modified
30000
10500
0
Form and Instruction
57.114
Urinary Tract infection (UTI)
57.115 Custom Event
Modified
54600
32760
0
Form
CDC 57.115
Custom Event
57.116 Denominators for Neonatal Intensive Care Unit (NICU)
Modified
13200
880
0
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
0
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
0
Form
CDC 57.118
Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
57.120 Surgical Site Infection (SSI)
Modified
54000
32400
0
Form
CDC 57.120
Surgical Site Infection
57.121 Denominators for Procedure
Modified
3612000
662200
0
Form and Instruction
57.121
Denominator 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
Modified
30000
2500
0
Form and Instruction
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
48000
4000
0
Form and Instruction
57.124
Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables
57.125 Central Line Insertion Practices Adherence Monitoring Form
Modified
106500
46150
0
Form
CDC 57.125
Central Line Insertion Practices Adherence Monitoring
Form
CDC 57.115
Central Line Insertion Practices Adherence Monitoring (revised GISAB questions)
57.126 MDRO or CDI Infection Event
Modified
7920
4092
0
Form
CDC 57.126
MDRO or CDI Infection Event
Form
57.126
MDRO or CDI Infection Event (with revised GISAB questions)
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring
Modified
159500
39875
0
Form
CDC 57.127
MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting
57.128 Laboratory Identified or CDI MDRO Event
Modified
379200
132720
0
Form and Instruction
CDC 57.128 Rev 7, v8.5
Lab ID Event
Form
57.128
Laboratory-identified MDRO or CDI Event (with revised GISAB questions)
57.129_Adult Sepsis_BLANK
Modified
12500
5208
0
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
Modified
17700
35400
0
Form
CDC 57.137
Long-Term Care Facility Component -- Annual Facility Survey
57.138 Laboratory-Identified MDRO or CDI Event for LTCF
Modified
47952
15984
0
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
0
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
0
Form and Instruction
57.140
57.140_LTCF UTI_Form_2022
Form and Instruction
57.140
Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF
Modified
24132
2011
0
Form
CDC 57.141
Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations
Modified
4068
2373
0
Form
CDC 57.142
Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF
Modified
1560
130
0
Form
CDC 57.143
Prevention Process Measures Monthly Monitoring
57.150 Patient Safety Component -- Annual Facility Survey for LTAC
Modified
620
847
0
Form and Instruction
57.150
Urinary Tract Infection (UTI) for LTCF
57.151 Patient Safety Component -- Annual Facility Survey for IRF
Modified
1340
1831
0
Form and Instruction
57.151
Patient Safety Component—Annual Facility Survey for IRF
57.200 Healthcare Personnel Safety Component Facility Survey
Modified
50
400
0
Form
CDC 57.200
Healthcare Personnel Safety - Annual Facility Survey
57.203 Healthcare Personnel Safety Reporting Plan
Modified
19500
0
0
Form
CDC 57.203
Healthcare Personnel Safety Monthly Reporting Plan
57.204 Healthcare Worker Demographic Data
Modified
10000
3333
0
Form
CDC 57.204
Healthcare Worker Demographic Data
57.205 Exposure to Blood and Body Fluids
Modified
2500
2500
0
Form
CDC 57.205
Exposure to Blood/Body Fluids
57.206 Healthcare Worker Prophylaxis/Treatment
Modified
1500
375
0
Form
CDC 57.206
Healthcare Worker Prophylaxis/Treatment
57.207 Follow-up Laboratory Testing
Modified
2500
625
0
Form
CDC 57.207
Follow-up Laboratory Testing
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza
Modified
2500
417
0
Form
CDC 57.210
HCW Prophylaxis/Treatment-Influenza
57.300 Hemovigilance Module Annual Survey -- Acute Care Facility
Modified
500
717
0
Form
CDC 57.300
Hemovigilance Module - Annual Survey
Form
57.300
Hemovigilance Module Annual Survey (with revised GISAB questions)
57.301 Hemovigilance Module Monthly Reporting Plan
Modified
6000
6000
0
Form and Instruction
57.301
57.301_HV Monthly Reporting Plan_BLANK
57.303 Hemovigilance Module Monthly Reporting Denominators
Modified
6000
7000
0
Form and Instruction
CDC 57.303
Hemovigilance Module Monthly Reporting Denominators
57.305 Hemovigilance Incident
Modified
5000
833
0
Form
CDC 57.305
Hemovigilance Module Incident
57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility
Modified
500
300
0
Form
57.306
Hemovigilance Module Annual Survey - Non-acute Care Facility
Form
CDC 57.306
Hemovigilance Module Annual Facility Survey - Non-acute Care Facilities (with revised GISAB questions)
57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction
Modified
2000
700
0
Form
57.307
Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction
Form
CDC 57.307
Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction (with revised GISAB questions)
57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction
Modified
2000
700
0
Form
57.308
Hemovigilance Adverse Reaction - Allergic Transfusion Reaction
Form
CDC 57.308
Hemovigilance Module Adverse Reaction Allergic Transfusion Reaction (with revised GISAB questions)
57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction
Modified
500
175
0
Form
CDC 57.309
Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction
Form
CDC 57.309
Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction (with revised GISAB questions)
57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction
Modified
1000
350
0
Form
57.310
Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction
Form
CDC 57.310
Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction (with revised GISAB questions)
57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction
Modified
2000
700
0
Form
CDC 57.311
Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction
Form
CDC 57.311
57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction (with revised GISAB questions)
57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction
Modified
500
175
0
Form
57.312
Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction
Form
CDC 57.312
Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction (with modified GISAB questions)
57.313 Hemovigilance Adverse Reaction - Infection
Modified
500
175
0
Form
57.313
Hemovigilance Adverse Reaction - Infection
Form
CDC 57.313
Hemovigilance Adverse Reaction - Infection (with revised GISAB questions)
57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura
Modified
500
175
0
Form
57.314
Hwemovilgilance Adverse Reaction - Post Transfusion Purpura
Form
CDC 57.314
Hemovigilance Adverse Reaction - Post Transfusion Purpura (with revised GISAB questions)
57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea
Modified
500
175
0
Form
CDC 57.315
Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea
Form
CDC 57.315
Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea (with revised GISAB questions)
57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease
Modified
500
175
0
Form
CDC 57.316
Hemovigilance Adverse Reaction - Transfusin Associated Graft vs. Host Disease
Form
CDC 57.316
Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease (with revised GISAB questions)
57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury
Modified
500
175
0
Form
57.317
Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury
Form
CDC 57.317
Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury (with revised GISAB questions)
57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload
Modified
1000
350
0
Form
57.318
Hemoviligance Adverse Reaction - Transfusion Associated Circulatory Overload
Form
CDC 57.318
Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload (with revised GISAB questions)
57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction
Modified
500
175
0
Form
CDC 57.319
Hemovigilance Adverse Reaction - Unknown Transfusion Reaction
Form
CDC 57.319
Hemovigilance Adverse Reaction - Unknown Transfusion Reaction (with modified GISAB questions)
57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction
Modified
500
175
0
Form
57.320
Hemovigilance Adverse Reaction - Other Transfusion Reaction
Form
CDC 57.320
Hemovigilance Adverse Reaction - Other Transfusion Reaction (with revised GISAB questions)
57.400 Outpatient Procedure - Annual Facility Survey
Modified
700
117
0
Form
CDC 57.400
Outpatient Procedure Component - Annual Facility Survey
57.401 Outpatient Procedure - Monthly Reporting Plan
Modified
8400
2100
0
Form
CDC 57.401
Outpatient Procedure Component - Monthly Reporting Plan
57.402 Outpatient Procedure Component Event
Modified
200
137
0
Form
CDC 57.402
Outpatient Procedure - Component Event
57.403 Outpatient Procedure Component - Monthly Denominators and Summary
Modified
80000
53333
0
Form
CDC 57.403
Outpatient Procedure - Monthly Denominators and Summary
57.404 Outpatient Procedure Component - SSI Denominators
Modified
70000
47833
0
Form
57.404
Outpatient Procedure Component - SSI Denominators
57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event
Modified
3500
2392
0
Form
CDC 57.405
Outpatient Procedure Component - SSI Denominators
57.500 Outpatient Dialysis Center Practices Survey
Modified
7200
1440
0
Form and Instruction
57.500
Home Dialysis Center Practices Survey
57.501 Dialysis Monthly Reporting Plan
Modified
86400
7200
0
Form
CDC 57.501
NHSN Registration Form
57.502 Dialysis Event
Modified
216000
93600
0
Form and Instruction
CDC 57.502
Dialysis Event
57.503 Denominators for Outpatient Dialysis
Modified
216000
36000
0
Form
CDC 57.503
Demominators for Dialysis Event Surveillance
57.504 Prevention Process Measures Monthly Monitoring for Dialysis
Modified
20760
25950
0
Form
CDC 57.504
Prevention Process Measures Monthly Monitoring for Dialysis
57.505 Dialysis Patient Influenza Vaccination
Modified
30750
5125
0
Form
CDC 57.505
Dialysis Patient Influenza Vaccination
57.506 Dialysis Patient Influenza Vaccination Denominator
Modified
3075
513
0
Form
CDC 57.506
Dialysis Patient Influenza Vaccination Denominator
57.507 Home Dialysis Center Practices Survey
Modified
430
215
0
Form
57.507
57.507 Home Dialysis Center Practices Survey
Form and Instruction
57.507
57.507_dialhomesurv_2020_final
Annual Healthcare Personnel Influenza Vaccination Summary
Unchanged
5000
10000
0
Form and Instruction
0920-0666
Annual Healthcare Personnel Influenza Vaccination Summary
Monthly Survey Patient Days & Nurse Staffing
Modified
30000
30000
0
Form and Instruction
NA
Monthly Survey Patient Days & Nurse Staffing
Form and Instruction
None
Monthly Survey Patient Days & Nurse Staffing
Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities
Unchanged
62400
62400
0
Form and Instruction
0920-0666
Weekly HCP Influenza Vaccination Cumulative Summary for Long-Term Care Facilities
Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities
Unchanged
6500
6500
0
Form and Instruction
0920-0666
Weekly HCP Influenza Vaccination Cumulative Summary Non-Long-Term Care Facilities
Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities
Unchanged
130000
130000
0
Form and Instruction
0920-0666
Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities
Total burden requested under this ICR:
6209922
1693215
0
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