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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