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
57.101 Facility Contact Information Modified 2000 333 0 Form CDC 57.101
57.103 Patient Safety Component - Annual Hospital Survey Modified 6765 10148 0 Form and Instruction None
57.104 NHSN Administrator Change Request Form Unchanged 800 67 0 Form and Instruction none
57.105 Group Contact Information Modified 1000 83 0 Form CDC 57.105
57.106 Patient Safety Monthly Reporting Plan Modified 93852 23463 0 Form and Instruction 57.106
57.108 Primary Bloodstream Infection (BSI) Modified 28875 18769 0 Form and Instruction 57.108
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
57.112 Ventilator-Associated Event (VAE) Modified 43704 21124 0 Form and Instruction 57.112
57.113 Pediatric Ventilator-Associated Event (PedVAE) Modified 334 173 0 Form and Instruction 57.113
57.114 Urinary Tract Infection (UTI) Modified 30000 10500 0 Form and Instruction 57.114
57.115 Custom Event Modified 54600 32760 0 Form CDC 57.115
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Modified 13200 880 0 Form CDC 57.116
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Modified 6000 500 0 Form CDC 57.117
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Modified 330000 27500 0 Form CDC 57.118
57.120 Surgical Site Infection (SSI) Modified 54000 32400 0 Form CDC 57.120
57.121 Denominators for Procedure Modified 3612000 662200 0 Form and Instruction 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 Modified 30000 2500 0 Form and Instruction 57.123
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Modified 48000 4000 0 Form and Instruction 57.124
57.125 Central Line Insertion Practices Adherence Monitoring Form Modified 106500 46150 0 Form CDC 57.125
Form CDC 57.115
57.126 MDRO or CDI Infection Event Modified 7920 4092 0 Form CDC 57.126
Form 57.126
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Modified 159500 39875 0 Form CDC 57.127
57.128 Laboratory Identified or CDI MDRO Event Modified 379200 132720 0 Form and Instruction CDC 57.128 Rev 7, v8.5
Form 57.128
57.129_Adult Sepsis_BLANK Modified 12500 5208 0 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 Modified 17700 35400 0 Form CDC 57.137
57.138 Laboratory-Identified MDRO or CDI Event for LTCF Modified 47952 15984 0 Form CDC 57.138
57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Modified 23976 7992 0 Form CDC 57.139
57.140 Urinary Tract Infection (UTI) for LTCF Modified 12204 7119 0 Form and Instruction 57.140
Form and Instruction 57.140
57.141 Monthly Reporting Plan for LTCF Modified 24132 2011 0 Form CDC 57.141
57.142 Denominators for LTCF Locations Modified 4068 2373 0 Form CDC 57.142
57.143 Prevention Process Measures Monthly Monitoring for LTCF Modified 1560 130 0 Form CDC 57.143
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Modified 620 847 0 Form and Instruction 57.150
57.151 Patient Safety Component -- Annual Facility Survey for IRF Modified 1340 1831 0 Form and Instruction 57.151
57.200 Healthcare Personnel Safety Component Facility Survey Modified 50 400 0 Form CDC 57.200
57.203 Healthcare Personnel Safety Reporting Plan Modified 19500 0 0 Form CDC 57.203
57.204 Healthcare Worker Demographic Data Modified 10000 3333 0 Form CDC 57.204
57.205 Exposure to Blood and Body Fluids Modified 2500 2500 0 Form CDC 57.205
57.206 Healthcare Worker Prophylaxis/Treatment Modified 1500 375 0 Form CDC 57.206
57.207 Follow-up Laboratory Testing Modified 2500 625 0 Form CDC 57.207
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Modified 2500 417 0 Form CDC 57.210
57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Modified 500 717 0 Form CDC 57.300
Form 57.300
57.301 Hemovigilance Module Monthly Reporting Plan Modified 6000 6000 0 Form and Instruction 57.301
57.303 Hemovigilance Module Monthly Reporting Denominators Modified 6000 7000 0 Form and Instruction CDC 57.303
57.305 Hemovigilance Incident Modified 5000 833 0 Form CDC 57.305
57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility Modified 500 300 0 Form 57.306
Form CDC 57.306
57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction Modified 2000 700 0 Form 57.307
Form CDC 57.307
57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction Modified 2000 700 0 Form 57.308
Form CDC 57.308
57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction Modified 500 175 0 Form CDC 57.309
Form CDC 57.309
57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction Modified 1000 350 0 Form 57.310
Form CDC 57.310
57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction Modified 2000 700 0 Form CDC 57.311
Form CDC 57.311
57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction Modified 500 175 0 Form 57.312
Form CDC 57.312
57.313 Hemovigilance Adverse Reaction - Infection Modified 500 175 0 Form 57.313
Form CDC 57.313
57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura Modified 500 175 0 Form 57.314
Form CDC 57.314
57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea Modified 500 175 0 Form CDC 57.315
Form CDC 57.315
57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease Modified 500 175 0 Form CDC 57.316
Form CDC 57.316
57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury Modified 500 175 0 Form 57.317
Form CDC 57.317
57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload Modified 1000 350 0 Form 57.318
Form CDC 57.318
57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction Modified 500 175 0 Form CDC 57.319
Form CDC 57.319
57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction Modified 500 175 0 Form 57.320
Form CDC 57.320
57.400 Outpatient Procedure - Annual Facility Survey Modified 700 117 0 Form CDC 57.400
57.401 Outpatient Procedure - Monthly Reporting Plan Modified 8400 2100 0 Form CDC 57.401
57.402 Outpatient Procedure Component Event Modified 200 137 0 Form CDC 57.402
57.403 Outpatient Procedure Component - Monthly Denominators and Summary Modified 80000 53333 0 Form CDC 57.403
57.404 Outpatient Procedure Component - SSI Denominators Modified 70000 47833 0 Form 57.404
57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Modified 3500 2392 0 Form CDC 57.405
57.500 Outpatient Dialysis Center Practices Survey Modified 7200 1440 0 Form and Instruction 57.500
57.501 Dialysis Monthly Reporting Plan Modified 86400 7200 0 Form CDC 57.501
57.502 Dialysis Event Modified 216000 93600 0 Form and Instruction CDC 57.502
57.503 Denominators for Outpatient Dialysis Modified 216000 36000 0 Form CDC 57.503
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Modified 20760 25950 0 Form CDC 57.504
57.505 Dialysis Patient Influenza Vaccination Modified 30750 5125 0 Form CDC 57.505
57.506 Dialysis Patient Influenza Vaccination Denominator Modified 3075 513 0 Form CDC 57.506
57.507 Home Dialysis Center Practices Survey Modified 430 215 0 Form 57.507
Form and Instruction 57.507
Annual Healthcare Personnel Influenza Vaccination Summary Unchanged 5000 10000 0 Form and Instruction 0920-0666
Monthly Survey Patient Days & Nurse Staffing Modified 30000 30000 0 Form and Instruction NA
Form and Instruction None
Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Unchanged 62400 62400 0 Form and Instruction 0920-0666
Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities Unchanged 6500 6500 0 Form and Instruction 0920-0666
Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Unchanged 130000 130000 0 Form and Instruction 0920-0666
Total burden requested under this ICR: 6209922 1693215 0  
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