The National Healthcare Safety Network (NHSN)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form No. 57.75FF Healthcare Worker Influenza Vaccination	Form	Modified	Available
Form Form No. 57.75LL MDRO Prevention Process Monitoring	Form	New	Available
Form Form No. 57.75JJ Central Line Insertion Practices Adherence Monitoring	Form	New	Available
Form Form No. 57.75II Post-Season on Influenza Vaccination Programs for Healthcare Workers	Form	New	Repair queued
Form Form No. 57.75HH Pre-Season Survey on Influenza Vaccination Programs	Form	New	Available
Form Form No. 57.75GG Healthcare Worker Influenza Antiviral Medication Administration	Form	New	Available
NHSN HCPSC Implementation of Engineering Controls OMB version - Form 30 01-09-06.ppt	Supplementary Document	Uploaded 2006-12-22	Available
Facility survey_OMB version.ppt	Supplementary Document	Uploaded 2006-12-22	Repair queued
Laboratory Testing_OMB version.ppt	Supplementary Document	Uploaded 2006-12-22	Available
Healthcare Personnel Safety Reporting Plan (CDC 57 75B)_NHSN_OMB version.ppt	Supplementary Document	Uploaded 2006-12-22	Available
Patient safety reporting form_OMB version.ppt	Supplementary Document	Uploaded 2006-12-22	Available
0920-0666 NHSN Justification 12.22.06.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2006-12-22	Available
Blood Exposure _OMB version.ppt	Supplementary Document	Uploaded 2006-12-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7134	The National Healthcare Safety Network	Form	Modified	Healthcare Worker Influenza Vaccination
46694	The National Healthcare Safety Network	Form	New	MDRO Prevention Process Monitoring
46693	The National Healthcare Safety Network	Form	New	Central Line Insertion Practices Adherence Monitoring
46692	The National Healthcare Safety Network	Form	New	Post-Season on Influenza Vaccination Programs for Healthcare Workers
46691	The National Healthcare Safety Network	Form	New	Pre-Season Survey on Influenza Vaccination Programs
46690	The National Healthcare Safety Network	Form	New	Healthcare Worker Influenza Antiviral Medication Administration

ICR Details

OMB Control No: 0920-0666	ICR Reference No: 200701-0920-002
Status: Historical Inactive	Previous ICR Reference No: 200409-0920-012
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: The National Healthcare Safety Network (NHSN)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 03/14/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/12/2007
Terms of Clearance: Withdrawn per CDC request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2008	02/29/2008	02/29/2008
Responses	174,395	0	174,395
Time Burden (Hours)	65,817	0	65,817
Cost Burden (Dollars)	39,600,000	0	39,600,000

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Abstract: The National Healthcare Safety Network will combine three surveillance systems into one. The data will be used to determine the magnitude of various healthcare-associated adverse events and trends in the rates of these events among patients and healthcare personnel with similar risks and exposures. Data will be gathered on antibiotic resistance to describe the epidemiology and to understand therapies.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
The National Healthcare Safety Network	Form No. 57.75LL	MDRO Prevention Process Monitoring
The National Healthcare Safety Network	Form No. 57.75FF	Healthcare Worker Influenza Vaccination
The National Healthcare Safety Network	Form No. 57.75II	Post-Season on Influenza Vaccination Programs for Healthcare Workers
The National Healthcare Safety Network	Form No. 57.75GG	Healthcare Worker Influenza Antiviral Medication Administration
The National Healthcare Safety Network	Form No. 57.75HH	Pre-Season Survey on Influenza Vaccination Programs
The National Healthcare Safety Network	Form No. 57.75JJ	Central Line Insertion Practices Adherence Monitoring

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: As noted in the terms of clearance, the changes to NHSN are requested to add additional forms that will enable the collection of process measures as well as outcomes by the system. In addition, proposed modifications to the already approved forms were made either to simplify data analysis or to accommodate the new data collection elements. The burden change of 10,780 additional burden hours will increase the burden hours from 65,817 to 76,597. There will be no change to the number of respondents and the number of responses will increase from 174,395 to 244,075, which is a difference of 69,680.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/22/2006

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