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 Modified 2000 333 0 Form CDC 57.101
57.103 Patient Safety Component - Annual Hospital Survey Modified 5400 12420 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) Modified 72000 51600 0 Form and Instruction 57.108
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Modified 3600 1980 0 Form and Instruction 57.111
57.112 Ventilator-Associated Event (VAE) Modified 43704 22580 0 Form and Instruction 57.112
57.113 Pediatric Ventilator-Associated Event (PedVAE) Modified 334 184 0 Form and Instruction 57.113
57.114 Urinary Tract Infection (UTI) Modified 72000 30000 0 Form and Instruction 57.114
57.115 Custom Event Modified 54600 34580 0 Form CDC 57.115
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Unchanged 13200 52800 0 Form CDC 57.116
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Unchanged 6000 30000 0 Form CDC 57.117
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Unchanged 330000 1650000 0 Form CDC 57.118
57.120 Surgical Site Infection (SSI) Modified 45600 9880 0 Form CDC 57.120
57.121 Denominators for Procedure Modified 45600 9880 0 Form and Instruction 57.121
57.122 HAI Progress Report State Health Department Survey Unchanged 55 46 0 Form CDC 55.122
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Modified 66000 5500 0 Form and Instruction 57.123
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Modified 66000 5500 0 Form and Instruction 57.124
57.125 Central Line Insertion Practices Adherence Monitoring Form Removed 0 0 0 Form CDC 57.125
57.126 MDRO or CDI Infection Event Modified 8640 4752 0 Form CDC 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 Modified 57600 22080 0 Form 57.128
57.129_Adult Sepsis Unchanged 600 280 0 Form 57.129
57.130 Pathogens of High Consequence Modified 1332250 777146 0 Form and Instruction 57.130
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Initial Set up Modified 4980 124500 0 Other-OMB Header and Burden Statement
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Yearly Maintenance Modified 20 400 0 Other-OMB Header and Burden Statement
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist Modified 5500 917 0 Form and Instruction 57.132
57.132 - Patient Safety Digital Reporting Plan (RPS CSV) Modified 9125 304 0 Form and Instruction 57.132
57.137 Long Term care Facility Component--Annual Facility Survey Unchanged 6270 14108 0 Form CDC 57.137
57.138 Laboratory-Identified MDRO or CDI Event for LTCF Modified 6864 2517 0 Form CDC 57.138
57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Unchanged 8856 1476 0 Form CDC 57.139
57.140 Urinary Tract Infection (UTI) for LTCF Modified 8952 5520 0 Form and Instruction 57.140
57.141 Monthly Reporting Plan for LTCF Unchanged 6552 546 0 Form CDC 57.141
57.142 Denominators for LTCF Locations Unchanged 8688 5068 0 Form CDC 57.142
57.143 Prevention Process Measures Monthly Monitoring for LTCF Unchanged 5208 434 0 Form CDC 57.143
57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA Modified 198000 16500 0 Form and Instruction 57.145
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Modified 395 658 0 Form and Instruction 57.150
57.151 Patient Safety Component -- Annual Facility Survey for IRF Modified 395 553 0 Form and Instruction 57.151
57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Modified 57 29 0 Form CDC 57.300
57.301 Hemovigilance Module Monthly Reporting Plan Modified 235 78 0 Form and Instruction 57.301
57.303 Hemovigilance Module Monthly Reporting Denominators Modified 3 3 0 Form and Instruction CDC 57.303
57.305 Hemovigilance Incident Removed 0 0 0 Form CDC 57.305
57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility Removed 0 0 0 Form 57.306
57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction Removed 0 0 0 Form 57.307
57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction Removed 0 0 0 Form 57.308
57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction Removed 0 0 0 Form CDC 57.309
57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction Removed 0 0 0 Form 57.310
57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction Removed 0 0 0 Form CDC 57.311
57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction Removed 0 0 0 Form 57.312
57.313 Hemovigilance Adverse Reaction - Infection Removed 0 0 0 Form 57.313
57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura Removed 0 0 0 Form 57.314
57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea Removed 0 0 0 Form CDC 57.315
57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease Removed 0 0 0 Form CDC 57.316
57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury Removed 0 0 0 Form 57.317
57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload Removed 0 0 0 Form CDC 57.318
57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction Removed 0 0 0 Form CDC 57.319
57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction Removed 0 0 0 Form 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 700 0 Form CDC 57.401
57.402 Outpatient Procedure Component Event Modified 50 35 0 Form CDC 57.402
57.403 Outpatient Procedure Component - Monthly Denominators and Summary Unchanged 20000 6667 0 Form CDC 57.403
57.404 Outpatient Procedure Component - SSI Denominators Modified 30000 11000 0 Form 57.404
57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Modified 10800 7020 0 Form CDC 57.405
57.500 Outpatient Dialysis Center Practices Survey Modified 6900 17135 0 Form and Instruction 57.500
57.501 Dialysis Monthly Reporting Plan Modified 88800 7400 0 Form CDC 57.501
57.502 Dialysis Event Modified 222000 185000 0 Form and Instruction CDC 57.502
57.503 Denominators for Outpatient Dialysis Unchanged 88800 14800 0 Form CDC 57.503
57.504 Prevention Process Measures Monthly Monitoring for Dialysis Unchanged 20760 20760 0 Form CDC 57.504
57.507 Home Dialysis Center Practices Survey Modified 550 596 0 Form 57.507
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up Removed 0 0 0 Form and Instruction 57.600
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance Removed 0 0 0 Form and Instruction 57.600
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist Removed 0 0 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 Removed 0 0 0 Form and Instruction 57.700
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance Removed 0 0 0 Form and Instruction 57.700
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist Modified 5500 458 0 Form and Instruction 57.700
57.701 - Glycemic Control Module-HYPO Annual Survey Modified 10 25 0 Form and Instruction 57.701
AUR Microbiolgy Data Electronic Upload Specification Tables (Yearly Maintenance) Modified 8600 17200 0 Form 57.123
AUR Microbiology Data Electronic Upload Specification Tables (Initial Set-up) Modified 1200 96000 0 Form 57.123
AUR Pharmacy Data Electronic Upload Specification Tables (Initial Set-up) Modified 800 32000 0 Form 57.124
AUR Pharmacy Data Electronic Upload Specification Tables (Yearly Maintenance) Modified 4700 9400 0 Form 57.124
All Hazards Modified 2792980 232748 0 Form and Instruction 57.803
Annual Healthcare Personnel Influenza Vaccination Summary (CSV) Unchanged 1920 1760 0 Form 57.214
Annual Healthcare Personnel Influenza Vaccination Summary (manual) Unchanged 22440 44880 0 Form and Instruction CDC 57.214
Bed Capacity-IT Initial Set Up Unchanged 25 8 0 Form and Instruction 57.802
Billing Code Data: 837I Upload Modified 66000 5500 0 Form 57.800
Claims Data - Initial IT Set-Up New 5500 4125 0 Other-data file
External Validation Summary Report Unchanged 40 10 0 Form and Instruction 57.801
Hemovigilance Module Monthly Incident Summary Modified 3 1 0 Form and Instruction CDC 57.302
Late Onset Sepsis / Meningitis Event Form: Data Table for Monthly Electronic Upload Modified 1800 150 0 Form and Instruction 57.602
Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) Modified 1800 150 0 Form and Instruction 57.601
Monthly Survey Patient Days & Nurse Staffing Unchanged 30000 150000 0 Form and Instruction 57.408
NHSN FHIR Digital Quality Measures (dQMs) New 50 21 0 Form and Instruction 57.900
NHSN Help Desk Customer Satisfaction Survey Unchanged 26400 880 0 Form and Instruction 57.102
NHSNCoLab Pilot Site Demographics New 21 9 0 Form and Instruction 57.901
NHSNCoLab Pilot Site Technical Assessment New 21 9 0 Form and Instruction 57.902
Patient Safety Attestation Modified 3500 583 0 Form and Instruction 57.133
Patient Safety Component Digistal Measure Reporting Plan (RPS ONLY Daily FHIR Submission) - Yearly Maintenance New 5 67 0 Other-data file
Patient Safety Component Digistal Measure Reporting Plan (RPS ONLY Daily FHIR Submission) -IT Intial Set Up New 495 8250 0 Other-data file
Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel Unchanged 15426 11570 0 Form and Instruction 57.215
Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities Unchanged 1404 585 0 Form and Instruction CDC 57.211
Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities (CSV) Removed 0 0 0 Form 57.211
Total burden requested under this ICR: 6302285 3848567 0  
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