Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
57.100 NHSN Registration Form Unchanged 2000 167 0 Form CDC 57.100 NHSN Registration Form
57.101 Facility Contact Information Unchanged 2000 333 0 Form CDC 57.101 Facility Contact Information
57.103 Patient Safety Component - Annual Hospital Survey Modified 5311 11950 0 Form and Instruction 57.103 Patient Safety Component-Annual Hospital Survey
57.104 NHSN Administrator Change Request Form Unchanged 800 67 0 Form and Instruction none Facility Administrator Change Request
57.105 Group Contact Information Unchanged 1000 83 0 Form CDC 57.105 Group Contact Information
57.106 Patient Safety Monthly Reporting Plan Unchanged 93852 23463 0 Form and Instruction 57.106 Patient Safety Monthly Reporting Plan
57.108 Primary Bloodstream Infection (BSI) Unchanged 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) Unchanged 3600 1860 0 Form and Instruction 57.111 Pneumonia (PNEU)
57.112 Ventilator-Associated Event (VAE) Unchanged 43704 21124 0 Form and Instruction 57.112 Ventilator Associated Event (VAE)
57.113 Pediatric Ventilator-Associated Event (PedVAE) Unchanged 334 173 0 Form and Instruction 57.113 Pediatric Ventilator-Associated Event (PedVAE)
57.114 Urinary Tract Infection (UTI) Unchanged 30000 10500 0 Form and Instruction 57.114 Urinary Tract infection (UTI)
57.115 Custom Event Unchanged 54600 32760 0 Form CDC 57.115 Custom Event
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Unchanged 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) Unchanged 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) Unchanged 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 45600 27360 0 Form CDC 57.120 Surgical Site Infection
57.121 Denominators for Procedure Modified 45600 7600 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 66000 5500 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 66000 5500 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 Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 12500 5208 0 Form 57.129 Adult Sepsis_
57.130 - Patient Safety Component CSV Data Collection-Infection Preventionist CSV Data Collection-Infection Preventionist New 2007500 66917 0 Form and Instruction 57.130 Reporting Plan - Respiratory Pathogens Surveillance (RPS)
57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Yearly Maintenance New 5500 110000 0 Form and Instruction 57.130 Reporting Plan - Respiratory Pathogens Surveillance (RPS)
57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS)-Infection Preventionist New 5500 550 0 Form and Instruction 57.130 Reporting Plan - Respiratory Pathogens Surveillance (RPS)
57.130 Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Initial Set up New 5500 148500 0 Form and Instruction 57.130 Reporting Plan - Respiratory Pathogens Surveillance (RPS)
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Initial Set up New 5500 148500 0 Form and Instruction 57.132 Reporting Plan HOB and HTCDI
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Yearly Maintenance New 5500 110000 0 Form and Instruction 57.132 Reporting Plan HOB and HTCDI
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist New 33000 3300 0 Form and Instruction 57.132 Reporting Plan HOB and HTCDI
57.133 - Patient Safety Component FHIR Measures-VTE Module- Infection Preventionist New 33000 3300 0 Form and Instruction 57.133 Reporting Plan Venous Thromboembolism
57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Initial Set up New 5500 148500 0 Form and Instruction 57.133 Reporting Plan Venous Thromboembolism
57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Yearly Maintenance New 5500 110000 0 Form and Instruction 57.133 Reporting Plan Venous Thromboembolism
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 26064 8688 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 12228 4076 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 Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF Modified 13188 3297 0 Form CDC 57.141 Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations Modified 8568 4998 0 Form CDC 57.142 Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF Modified 4284 357 0 Form CDC 57.143 Prevention Process Measures Monthly Monitoring
57.144 - Long Term Care Respiratory Tract Infections (RTI) Module New 396000 165000 0 Form and Instruction 57.144 Long-Term Care RTI Module
57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA New 198000 16500 0 Form and Instruction 57.145 LTC-AU Module
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Modified 392 581 0 Form and Instruction 57.150 Urinary Tract Infection (UTI) for LTCF
57.151 Patient Safety Component -- Annual Facility Survey for IRF Modified 1160 1721 0 Form and Instruction 57.151 Patient Safety Component—Annual Facility Survey for IRF
57.200 Healthcare Personnel Safety Component Facility Survey Unchanged 50 400 0 Form CDC 57.200 Healthcare Personnel Safety - Annual Facility Survey
57.203 Healthcare Personnel Safety Reporting Plan Unchanged 19500 0 0 Form CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan
57.204 Healthcare Worker Demographic Data Unchanged 10000 3333 0 Form CDC 57.204 Healthcare Worker Demographic Data
57.205 Exposure to Blood and Body Fluids Unchanged 2500 2500 0 Form CDC 57.205 Exposure to Blood/Body Fluids
57.206 Healthcare Worker Prophylaxis/Treatment Unchanged 1500 375 0 Form CDC 57.206 Healthcare Worker Prophylaxis/Treatment
57.207 Follow-up Laboratory Testing Unchanged 2500 625 0 Form CDC 57.207 Follow-up Laboratory Testing
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Unchanged 2500 417 0 Form CDC 57.210 HCW Prophylaxis/Treatment-Influenza
57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Unchanged 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 Unchanged 6000 6000 0 Form and Instruction 57.301 57.301_HV Monthly Reporting Plan_BLANK
57.303 Hemovigilance Module Monthly Reporting Denominators Modified 6000 7700 0 Form and Instruction CDC 57.303 Hemovigilance Module Monthly Reporting Denominators
57.305 Hemovigilance Incident Unchanged 5000 833 0 Form CDC 57.305 Hemovigilance Module Incident
57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 500 167 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 Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 350 58 0 Form CDC 57.400 Outpatient Procedure Component - Annual Facility Survey
57.401 Outpatient Procedure - Monthly Reporting Plan Modified 4200 1050 0 Form CDC 57.401 Outpatient Procedure Component - Monthly Reporting Plan
57.402 Outpatient Procedure Component Event Modified 50 33 0 Form CDC 57.402 Outpatient Procedure - Component Event
57.403 Outpatient Procedure Component - Monthly Denominators and Summary Modified 20000 13333 0 Form CDC 57.403 Outpatient Procedure - Monthly Denominators and Summary
57.404 Outpatient Procedure Component - SSI Denominators Modified 30000 5000 0 Form 57.404 Outpatient Procedure Component - SSI Denominators
57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Modified 10800 6300 0 Form CDC 57.405 Outpatient Procedure Component - SSI Denominators
57.500 Outpatient Dialysis Center Practices Survey Modified 7400 1480 0 Form and Instruction 57.500 Home Dialysis Center Practices Survey
57.501 Dialysis Monthly Reporting Plan Modified 88800 7400 0 Form CDC 57.501 NHSN Registration Form
57.502 Dialysis Event Modified 88800 22200 0 Form and Instruction CDC 57.502 Dialysis Event
57.503 Denominators for Outpatient Dialysis Modified 177600 29600 0 Form CDC 57.503 Demominators for Dialysis Event Surveillance
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Unchanged 20760 25950 0 Form CDC 57.504 Prevention Process Measures Monthly Monitoring for Dialysis
57.505 Dialysis Patient Influenza Vaccination Unchanged 30750 5125 0 Form CDC 57.505 Dialysis Patient Influenza Vaccination
57.506 Dialysis Patient Influenza Vaccination Denominator Unchanged 3075 513 0 Form CDC 57.506 Dialysis Patient Influenza Vaccination Denominator
57.507 Home Dialysis Center Practices Survey Modified 450 270 0 Form 57.507 57.507 Home Dialysis Center Practices Survey
Form and Instruction 57.507 57.507_dialhomesurv_2020_final
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up New 5500 148500 0 Form and Instruction 57.600 Reporting Plan LOSMEN
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance New 5500 110000 0 Form and Instruction 57.600 Reporting Plan LOSMEN
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist New 33000 3300 0 Form and Instruction 57.600 Reporting Plan LOSMEN
57.600 - Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist New 66000 2200 0 Form and Instruction 57.600 Reporting Plan LOSMEN
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Initial Set up New 5500 148500 0 Form and Instruction 57.700 Reporting Plan Glycemic Control Module Hypoglycemia
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance New 5500 110000 0 Form and Instruction 57.700 Reporting Plan Glycemic Control Module Hypoglycemia
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist New 33000 3300 0 Form and Instruction 57.700 Reporting Plan Glycemic Control Module Hypoglycemia
57.701 - Glycemic Control Module-HYPO Annual Survey New 10 20 0 Form and Instruction 57.701 Glycemic Control module Hypo-Annual Hospital Survey
Annual Healthcare Personnel Influenza Vaccination Summary Unchanged 5000 10000 0 Form and Instruction 0920-0666 Annual Healthcare Personnel Influenza Vaccination Summary
Billing Code Data: 837I Upload New 22000 1833 0 Other-Template
Monthly Survey Patient Days & Nurse Staffing Unchanged 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 Modified 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: 5271534 2434196 0  
To view an IC, click on IC Title