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
57.101 Facility Contact Information Unchanged 2000 333 0 Form CDC 57.101
57.103 Patient Safety Component - Annual Hospital Survey Unchanged 5311 11950 0 Form and Instruction 57.103
57.104 NHSN Administrator Change Request Form Unchanged 800 67 0 Form and Instruction none
57.105 Group Contact Information Unchanged 1000 83 0 Form CDC 57.105
57.106 Patient Safety Monthly Reporting Plan Unchanged 93852 23463 0 Form and Instruction 57.106
57.108 Primary Bloodstream Infection (BSI) Unchanged 28875 18769 0 Form and Instruction 57.108
57.109 Becton Dickinson BACTECTM Blood Culture Media Bottles Shortage Impact Questionnaire New 3500 1167 0 Form and Instruction 57.109
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
57.112 Ventilator-Associated Event (VAE) Unchanged 43704 21124 0 Form and Instruction 57.112
57.113 Pediatric Ventilator-Associated Event (PedVAE) Unchanged 334 173 0 Form and Instruction 57.113
57.114 Urinary Tract Infection (UTI) Unchanged 30000 10500 0 Form and Instruction 57.114
57.115 Custom Event Unchanged 54600 32760 0 Form CDC 57.115
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Unchanged 13200 880 0 Form CDC 57.116
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Unchanged 6000 500 0 Form CDC 57.117
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Unchanged 330000 27500 0 Form CDC 57.118
57.120 Surgical Site Infection (SSI) Unchanged 45600 27360 0 Form CDC 57.120
57.121 Denominators for Procedure Unchanged 45600 7600 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 Unchanged 66000 5500 0 Form and Instruction 57.123
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Unchanged 66000 5500 0 Form and Instruction 57.124
57.125 Central Line Insertion Practices Adherence Monitoring Form Unchanged 106500 46150 0 Form CDC 57.125
Form CDC 57.115
57.126 MDRO or CDI Infection Event Unchanged 7920 4092 0 Form CDC 57.126
Form 57.126
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Unchanged 159500 39875 0 Form CDC 57.127
57.128 Laboratory Identified or CDI MDRO Event Unchanged 379200 132720 0 Form and Instruction CDC 57.128 Rev 7, v8.5
Form 57.128
57.129_Adult Sepsis_BLANK Unchanged 12500 5208 0 Form 57.129
57.130 - Patient Safety Component CSV Data Collection-Infection Preventionist CSV Data Collection-Infection Preventionist Unchanged 2007500 66917 0 Form and Instruction 57.130
57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Yearly Maintenance Unchanged 5500 110000 0 Form and Instruction 57.130
57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS)-Infection Preventionist Unchanged 5500 550 0 Form and Instruction 57.130
57.130 Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Initial Set up Unchanged 5500 148500 0 Form and Instruction 57.130
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Initial Set up Unchanged 5500 148500 0 Form and Instruction 57.132
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Yearly Maintenance Unchanged 5500 110000 0 Form and Instruction 57.132
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist Unchanged 33000 3300 0 Form and Instruction 57.132
57.133 - Patient Safety Component FHIR Measures-VTE Module- Infection Preventionist Unchanged 33000 3300 0 Form and Instruction 57.133
57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Initial Set up Unchanged 5500 148500 0 Form and Instruction 57.133
57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Yearly Maintenance Unchanged 5500 110000 0 Form and Instruction 57.133
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 Unchanged 17700 35400 0 Form CDC 57.137
57.138 Laboratory-Identified MDRO or CDI Event for LTCF Unchanged 26064 8688 0 Form CDC 57.138
57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Unchanged 12228 4076 0 Form CDC 57.139
57.140 Urinary Tract Infection (UTI) for LTCF Unchanged 12204 7119 0 Form and Instruction 57.140
57.141 Monthly Reporting Plan for LTCF Unchanged 9996 2499 0 Form CDC 57.141
57.142 Denominators for LTCF Locations Unchanged 8580 5005 0 Form CDC 57.142
57.143 Prevention Process Measures Monthly Monitoring for LTCF Unchanged 4284 357 0 Form CDC 57.143
57.144 - Long Term Care Respiratory Tract Infections (RTI) Module Unchanged 396000 165000 0 Form and Instruction 57.144
57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA Unchanged 198000 16500 0 Form and Instruction 57.145
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Unchanged 392 581 0 Form and Instruction 57.150
57.151 Patient Safety Component -- Annual Facility Survey for IRF Unchanged 1160 1721 0 Form and Instruction 57.151
57.200 Healthcare Personnel Safety Component Facility Survey Unchanged 50 400 0 Form CDC 57.200
57.203 Healthcare Personnel Safety Reporting Plan Unchanged 19500 0 0 Form CDC 57.203
57.204 Healthcare Worker Demographic Data Unchanged 10000 3333 0 Form CDC 57.204
57.205 Exposure to Blood and Body Fluids Unchanged 2500 2500 0 Form CDC 57.205
57.206 Healthcare Worker Prophylaxis/Treatment Unchanged 1500 375 0 Form CDC 57.206
57.207 Follow-up Laboratory Testing Unchanged 2500 625 0 Form CDC 57.207
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Unchanged 2500 417 0 Form CDC 57.210
57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Unchanged 500 717 0 Form CDC 57.300
Form 57.300
57.301 Hemovigilance Module Monthly Reporting Plan Unchanged 6000 6000 0 Form and Instruction 57.301
57.303 Hemovigilance Module Monthly Reporting Denominators Unchanged 6000 7700 0 Form and Instruction CDC 57.303
57.305 Hemovigilance Incident Unchanged 5000 833 0 Form CDC 57.305
57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility Unchanged 500 300 0 Form 57.306
Form CDC 57.306
57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction Unchanged 2000 700 0 Form 57.307
Form CDC 57.307
57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction Unchanged 2000 700 0 Form 57.308
Form CDC 57.308
57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction Unchanged 500 175 0 Form CDC 57.309
Form CDC 57.309
57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction Unchanged 1000 350 0 Form 57.310
Form CDC 57.310
57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction Unchanged 2000 700 0 Form CDC 57.311
Form CDC 57.311
57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction Unchanged 500 175 0 Form 57.312
Form CDC 57.312
57.313 Hemovigilance Adverse Reaction - Infection Unchanged 500 175 0 Form 57.313
Form CDC 57.313
57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura Unchanged 500 175 0 Form 57.314
Form CDC 57.314
57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea Unchanged 500 167 0 Form CDC 57.315
Form CDC 57.315
57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease Unchanged 500 175 0 Form CDC 57.316
Form CDC 57.316
57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury Unchanged 500 175 0 Form 57.317
Form CDC 57.317
57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload Unchanged 160 56 0 Form CDC 57.318
57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction Unchanged 500 175 0 Form CDC 57.319
Form CDC 57.319
57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction Unchanged 500 175 0 Form 57.320
Form CDC 57.320
57.400 Outpatient Procedure - Annual Facility Survey Unchanged 350 58 0 Form CDC 57.400
57.401 Outpatient Procedure - Monthly Reporting Plan Unchanged 4200 1050 0 Form CDC 57.401
57.402 Outpatient Procedure Component Event Unchanged 50 33 0 Form CDC 57.402
57.403 Outpatient Procedure Component - Monthly Denominators and Summary Unchanged 20000 13333 0 Form CDC 57.403
57.404 Outpatient Procedure Component - SSI Denominators Unchanged 30000 5000 0 Form 57.404
57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Unchanged 10800 6300 0 Form CDC 57.405
57.500 Outpatient Dialysis Center Practices Survey Unchanged 7400 1480 0 Form and Instruction 57.500
57.501 Dialysis Monthly Reporting Plan Unchanged 88800 7400 0 Form CDC 57.501
57.502 Dialysis Event Unchanged 88800 22200 0 Form and Instruction CDC 57.502
57.503 Denominators for Outpatient Dialysis Unchanged 177600 29600 0 Form CDC 57.503
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Unchanged 20760 25950 0 Form CDC 57.504
57.505 Dialysis Patient Influenza Vaccination Unchanged 30750 5125 0 Form CDC 57.505
57.506 Dialysis Patient Influenza Vaccination Denominator Unchanged 3075 513 0 Form CDC 57.506
57.507 Home Dialysis Center Practices Survey Unchanged 450 270 0 Form 57.507
Form and Instruction 57.507
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up Unchanged 5500 148500 0 Form and Instruction 57.600
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance Unchanged 5500 110000 0 Form and Instruction 57.600
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist Unchanged 33000 3300 0 Form and Instruction 57.600
57.600 - Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist Unchanged 66000 2200 0 Form and Instruction 57.600
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Initial Set up Unchanged 5500 148500 0 Form and Instruction 57.700
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance Unchanged 5500 110000 0 Form and Instruction 57.700
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist Unchanged 33000 3300 0 Form and Instruction 57.700
57.701 - Glycemic Control Module-HYPO Annual Survey Unchanged 10 20 0 Form and Instruction 57.701
Annual Healthcare Personnel Influenza Vaccination Summary Unchanged 5000 10000 0 Form and Instruction 0920-0666
Billing Code Data: 837I Upload Unchanged 22000 1833 0 Other-Template
Hemovigilance Module Monthly Incident Summary Unchanged 108 54 0 Form and Instruction CDC 57.302
Monthly Survey Patient Days & Nurse Staffing Unchanged 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: 5271122 2434332 0  
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