The National Healthcare Safety Network (NHSN)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CDC 57.106 Patient Safety Monthly Reporting Plan	Form	Modified	Available
Form 57.138 57.138_LabIDEvent_ LTCF_BLANK	Form	New	Available
Form CDC 57.213 Healthcare Personnel Influenza Vaccination Monthly Summary	Form	New	Available
Form CDC 57.139 MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF	Form	New	Available
Form CDC 57.137 Patient Safety Component --Annual Facility Survey for LTCF	Form	New	Available
Form CDC 57.304 Hemovigilance Module Adverse Reaction	Form	Modified	Available
Form CDC 57.305 Hemovigilance Module Incident	Form	Modified	Available
Form CDC 57.303 hemovigilance Module Monthly Reporting Denominators	Form	Modified	Available
Form CDC 57.302 Hemovigilance Module Monthly Incident Summary	Form	Modified	Available
Form CDC 57.301 Hemovigilance Module Monthly Reporting Plan	Form	Modified	Available
Form CDC 57.300 Hemovigilance Module Annual Facility Survey	Form	Modified	Available
Form 57.75CC List of Blood Isolates	Form	Removed	Available
Form CDC 57.200 Healthcare Personnel Safety Component Annual Facility Survey	Form	Modified	Available
Form CDC 57.208 Healthcare Worker Vaccination History	Form	Modified	Available
Form CDC 57.204 Healthcare Worker Demographic Data	Form	Modified	Available
Form CDC 57.206 Healthcare Worker Prophylaxis/Treatment	Form	Modified	Available
Form CDC 57.205 Exposure to Blood/Body Fluids	Form	Modified	Available
Form CDC 57.105 Group Contact Information	Form	Modified	Available
Form 57.75T Agreement to Participate and Consent	Form	Removed	Available
Form CDC 57.140 Urinary Tract Infection (UTI) for LTCF	Form	Modified	Available
Form CDC 57.103 Patient Safety Component --Annual Facility Survey	Form	Modified	Available
Form CDC 57.131 Vaccination Monthly Monitoring Form-- Patient-Level Method	Form	Modified	Available
Form CDC 57.101 Facility Contact Information	Form	Modified	Available
Form CDC 57.133 Patient Vaccination	Form	Modified	Available
Form CDC 57.124 Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables	Form	Modified	Available
Form CDC 57.130 Vaccination Monthly Monitoring Form-- Summary Method	Form	Modified	Available
Form CDC 57.123 Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables	Form	Modified	Available
Form CDC 57.100 NHSN Registration Form	Form	Modified	Available
Form CDC 57.121 Denominator for Procedure	Form	Modified	Available
Form CDC 57.128 Laboratory-identified MDRO or CDI Event	Form	Modified	Available
Form CDC 57.120 Surgical Site Infection (SSI)	Form	Modified	Available
Form CDC 57.126 MDRO or CDI Infection Event	Form	Modified	Available
Form CDC 57.119 Denominators for Outpatient Dialysis	Form	Modified	Available
Form CDC 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	Form	Modified	Available
Form CDC 57.118 Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)	Form	Modified	Available
Form CDC 57.207 Follow-up Laboratory Testing	Form	Modified	Available
Form CDC 57.117 Denominators for Specialty Care Area (SCA)	Form	Modified	Available
Form CDC 57.125 Central Line Insertion Practices Adherence Monitoring	Form	Modified	Available
Form CDC 57.116 Denominators for Neonatal Intensive Care Unit (NICU)	Form	Modified	Available
Form CDC 57.212 Post-season Survey on Influenza Vaccination Programs for Healthcare Personnel	Form	Modified	Available
Form CDC 57.211 Pre-season Survey on Influenza Vaccination Programs for Healthcare Personnel	Form	Modified	Available
Form CDC 57.114 Urinary Tract Infection (UTI)	Form	Modified	Available
Form CDC 57.210 Healthcare Worker Prophylaxis/Treatment	Form	Modified	Available
Form CDC 57.111 Pneumonia (PNEU)	Form	Modified	Available
Form CDC Form 57.209 Healthcare Worker Influenza Vaccination	Form	Modified	Available
Form CDC 57.109 Dialysis Event	Form	Modified	Available
Form 57.75DD Manual Categorization of Positive Cultures	Form	Removed	Available
Form CDC 57.108 Primary Bloodstream Infection (BSI)	Form	Modified	Available
Form CDC 57.104 Patient Safety Component--Outpatient Dialysis Center Practices Survey	Form	Modified	Available
Form CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan	Form	Modified	Available
Form CDC 57.202 Healthcare Worker Survey	Form	Modified	Available
G. Surveillance Methods Supporting Materials.zip	Supplementary Document	Uploaded 2011-03-07	Available
2. NHSN - Report of End of Human Research Review 0.1253.docx	Supplementary Document	Uploaded 2011-03-07	Available
3. NHSN 308d Request for Extension and Amendment.docx	Supplementary Document	Uploaded 2011-03-07	Available
2. NHSN 308d approval memo 2010.pdf	Supplementary Document	Uploaded 2011-03-07	Available
1. NHSN 308d approval 2010.pdf	Supplementary Document	Uploaded 2011-03-07	Available
4. Revision of Estimated Annual Cost Burden.docx	Supplementary Document	Uploaded 2011-03-07	Available
3. Revision of Estimated Annual Burden Hours.docx	Supplementary Document	Uploaded 2011-03-07	Available
2. Itemized IC Revisions and Justifications.docx	Supplementary Document	Uploaded 2011-03-07	Available
1. Explanations and justifications for proposed revisions to OMB 0920-0666.docx	Supplementary Document	Uploaded 2011-03-07	Available
3. 42 USC 242m.PDF	Supplementary Document	Uploaded 2011-03-07	Available
1. 42 USC 242b.PDF	Supplementary Document	Uploaded 2011-03-07	Available
B. 60 Day Federal Register Notice.pdf	Supplementary Document	Uploaded 2011-03-07	Available
2. 42 USC 242k.PDF	Supplementary Document	Uploaded 2011-03-07	Available
0920-0666 Revision SupSta A.0411 OMBv.1.doc	Supporting Statement A	Uploaded 2011-04-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7134	57.106_ Patient Safety Monthly Reporting Plan	Form	Modified	Patient Safety Monthly Reporting Plan
197371	57.138 Laboratory-identified MDRO or CDI Event for LTCF	Form	New	57.138_LabIDEvent_ LTCF_BLANK
197320	57.213_Healthcare Personnel Influenza Vaccination Monthly Summary	Form	New	Healthcare Personnel Influenza Vaccination Monthly Summary
197319	57.139_MDRO or CDI Prevention Process Measures Monthly Monitoring for LTCF	Form	New	MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF
197318	57.137_Patient Safety Component --Annual Facility Survey for LTCF	Form	New	Patient Safety Component --Annual Facility Survey for LTCF
190365	57.304_Hemovigilance Adverse Reaction	Form	Modified	Hemovigilance Module Adverse Reaction
190364	57.305_Hemovigilance Module Adverse Reaction	Form	Modified	Hemovigilance Module Incident
190363	57.303_Hemovigilance Module Monthly Reporting Denominators	Form	Modified	hemovigilance Module Monthly Reporting Denominators
190362	57.302_Hemovigilance Module Blood Product Incident Reporting - Summary Data	Form	Modified	Hemovigilance Module Monthly Incident Summary
190361	57.301_Hemovigilance Module Monthly Reporting Plan	Form	Modified	Hemovigilance Module Monthly Reporting Plan
190360	57.300_Hemovigilance Module Annual Survey	Form	Modified	Hemovigilance Module Annual Facility Survey
183583	List of Blood Isolates	Form	Removed	List of Blood Isolates
183582	57.200_Healthcare Personnel Safety Component Facility Survey	Form	Modified	Healthcare Personnel Safety Component Annual Facility Survey
183580	57.208_Healthcare Worker Vaccination History	Form	Modified	Healthcare Worker Vaccination History
183579	57.204_Healthcare Worker Demographic Data	Form	Modified	Healthcare Worker Demographic Data
183578	57.206_Healthcare Worker Post-Exposure Prophylaxis	Form	Modified	Healthcare Worker Prophylaxis/Treatment
183577	57.205_Exposure to Blood and Body Fluids	Form	Modified	Exposure to Blood/Body Fluids
183576	57.105_Group Contact Information	Form	Modified	Group Contact Information
183574	Agreement to Participate and Consent	Form	Removed	Agreement to Participate and Consent
183573	57.140 Urinary Tract Infection (UTI) for LTCF	Form	Modified	Urinary Tract Infection (UTI) for LTCF
183572	57.103_Patient Safety Component Annual Facility Survey	Form	Modified	Patient Safety Component --Annual Facility Survey
183571	57.131_High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B	Form	Modified	Vaccination Monthly Monitoring Form-- Patient-Level Method
183570	57.101_Facility Contact Information	Form	Modified	Facility Contact Information
183569	57.133_Patient Vaccination	Form	Modified	Patient Vaccination
183568	57.124_Antimicrobial Use and Resistence (AUR) - Pharmacy Data	Form	Modified	Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables
183567	57.130_Vaccination Monthly Monitoring Form - Summary Method	Form	Modified	Vaccination Monthly Monitoring Form-- Summary Method
183566	57.123_Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data	Form	Modified	Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables
183565	57.100_NHSN Registration Form	Form	Modified	NHSN Registration Form
183564	57.121_Denominators for Procedure	Form	Modified	Denominator for Procedure
183563	57.128_Laboratory Identified MDRO Event	Form	Modified	Laboratory-identified MDRO or CDI Event
183562	57.120_Surgical Site Infection (SSI)	Form	Modified	Surgical Site Infection (SSI)
183561	57.126_MDRO or CDI Infection Event	Form	Modified	MDRO or CDI Infection Event
183560	57.119_Denominators for Outpatient Dialysis	Form	Modified	Denominators for Outpatient Dialysis
183559	57.127_Multi-drug Resistant Organism (MDRO) Prevention Process and Outcome Measures Monthly Monitoring Form	Form	Modified	MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring
183558	57.118_Denominators for Intensive Care Unit (ICU) Other Locations (not NICU or SCA)	Form	Modified	Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
183557	57.207_Follow-up Laboratory Testing	Form	Modified	Follow-up Laboratory Testing
183556	57.117_Denominators for Specialty Care Area (SCA)	Form	Modified	Denominators for Specialty Care Area (SCA)
183555	57.125_Central Line Insertion Practices Adherence Monitoring Form	Form	Modified	Central Line Insertion Practices Adherence Monitoring
183554	57.116_Denominators for Neonatal Intensive Care Unit (NICU)	Form	Modified	Denominators for Neonatal Intensive Care Unit (NICU)
183553	57.212_Post-Season Survey on Influenza Vaccination Programs for Healthcare Personnel	Form	Modified	Post-season Survey on Influenza Vaccination Programs for Healthcare Personnel
183552	57.211_Preseason Survey on Influenza Vaccination Program for Healthcare Personnel	Form	Modified	Pre-season Survey on Influenza Vaccination Programs for Healthcare Personnel
183551	57.114_Urinary Tract Infection (UTI)	Form	Modified	Urinary Tract Infection (UTI)
183550	57.210_Healthcare Worker Influenza Antiviral Medication Administration	Form	Modified	Healthcare Worker Prophylaxis/Treatment
183549	57.111_Pneumonia (PNEU)	Form	Modified	Pneumonia (PNEU)
183548	57.209_Healthcare Worker Influenza Vaccination	Form	Modified	Healthcare Worker Influenza Vaccination
183547	57.109_Dialysis Event	Form	Modified	Dialysis Event
183546	Manual Categorization of Positive Blood Cultures	Form	Removed	Manual Categorization of Positive Cultures
183545	57.108_Primary Bloodstream Infection (BSI)	Form	Modified	Primary Bloodstream Infection (BSI)
183544	57.104_Patient Safety Component-- Outpatient Dialysis Center Practice Survey	Form	Modified	Patient Safety Component--Outpatient Dialysis Center Practices Survey
183543	57.203_Healthcare Personnel Safety Reporting Plan	Form	Modified	Healthcare Personnel Safety Monthly Reporting Plan
183542	57.202_Healthcare Worker Survey	Form	Modified	Healthcare Worker Survey

ICR Details

OMB Control No: 0920-0666	ICR Reference No: 201104-0920-012
Status: Historical Inactive	Previous ICR Reference No: 200908-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: The National Healthcare Safety Network (NHSN)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted and continue	Conclusion Date: 04/28/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/14/2011
Terms of Clearance: This collection requires a Part B.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2012	36 Months From Approved	09/30/2012
Responses	9,620,950	0	9,620,950
Time Burden (Hours)	5,172,244	0	5,172,244
Cost Burden (Dollars)	162,000	0	162,000

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Abstract: The NHSN is a knowledge system for accumulating, exchanging and integrating relevant information and resources among private and public stakeholders to support local and national efforts to protect patients and healthcare personnel by promoting healthcare safety. Specifically, 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 or exposures. This revision adds a Hemovigilance module to develop a national system for outcome surveillance that included recipients of blood and blood products, and deletes two forms no longer needed by the NHSN.

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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
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 62833	10/13/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 12119	03/04/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 48

table that charts list of burden

IC Title	Form No.	Form Name
57.100_NHSN Registration Form	CDC 57.100	NHSN Registration Form
57.101_Facility Contact Information	CDC 57.101	Facility Contact Information
57.103_Patient Safety Component Annual Facility Survey	CDC 57.103	Patient Safety Component --Annual Facility Survey
57.104_Patient Safety Component-- Outpatient Dialysis Center Practice Survey	CDC 57.104	Patient Safety Component--Outpatient Dialysis Center Practices Survey
57.105_Group Contact Information	CDC 57.105	Group Contact Information
57.106_ Patient Safety Monthly Reporting Plan	CDC 57.106	Patient Safety Monthly Reporting Plan
57.108_Primary Bloodstream Infection (BSI)	CDC 57.108	Primary Bloodstream Infection (BSI)
57.109_Dialysis Event	CDC 57.109	Dialysis Event
57.111_Pneumonia (PNEU)	CDC 57.111	Pneumonia (PNEU)
57.114_Urinary Tract Infection (UTI)	CDC 57.114	Urinary Tract Infection (UTI)
57.116_Denominators for Neonatal Intensive Care Unit (NICU)	CDC 57.116	Denominators for Neonatal Intensive Care Unit (NICU)
57.117_Denominators for Specialty Care Area (SCA)	CDC 57.117	Denominators for Specialty Care Area (SCA)
57.118_Denominators for Intensive Care Unit (ICU) Other Locations (not NICU or SCA)	CDC 57.118	Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
57.119_Denominators for Outpatient Dialysis	CDC 57.119	Denominators for Outpatient Dialysis
57.120_Surgical Site Infection (SSI)	CDC 57.120	Surgical Site Infection (SSI)
57.121_Denominators for Procedure	CDC 57.121	Denominator for Procedure
57.123_Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data	CDC 57.123	Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables
57.124_Antimicrobial Use and Resistence (AUR) - Pharmacy Data	CDC 57.124	Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables
57.125_Central Line Insertion Practices Adherence Monitoring Form	CDC 57.125	Central Line Insertion Practices Adherence Monitoring
57.126_MDRO or CDI Infection Event	CDC 57.126	MDRO or CDI Infection Event
57.127_Multi-drug Resistant Organism (MDRO) Prevention Process and Outcome Measures Monthly Monitoring Form	CDC 57.127	MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring
57.128_Laboratory Identified MDRO Event	CDC 57.128	Laboratory-identified MDRO or CDI Event
57.130_Vaccination Monthly Monitoring Form - Summary Method	CDC 57.130	Vaccination Monthly Monitoring Form-- Summary Method
57.131_High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B	CDC 57.131	Vaccination Monthly Monitoring Form-- Patient-Level Method
57.133_Patient Vaccination	CDC 57.133	Patient Vaccination
57.137_Patient Safety Component --Annual Facility Survey for LTCF	CDC 57.137	Patient Safety Component --Annual Facility Survey for LTCF
57.138 Laboratory-identified MDRO or CDI Event for LTCF	57.138	57.138_LabIDEvent_ LTCF_BLANK
57.139_MDRO or CDI Prevention Process Measures Monthly Monitoring for LTCF	CDC 57.139	MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF
57.140 Urinary Tract Infection (UTI) for LTCF	CDC 57.140	Urinary Tract Infection (UTI) for LTCF
57.200_Healthcare Personnel Safety Component Facility Survey	CDC 57.200	Healthcare Personnel Safety Component Annual Facility Survey
57.202_Healthcare Worker Survey	CDC 57.202	Healthcare Worker Survey
57.203_Healthcare Personnel Safety Reporting Plan	CDC 57.203	Healthcare Personnel Safety Monthly Reporting Plan
57.204_Healthcare Worker Demographic Data	CDC 57.204	Healthcare Worker Demographic Data
57.205_Exposure to Blood and Body Fluids	CDC 57.205	Exposure to Blood/Body Fluids
57.206_Healthcare Worker Post-Exposure Prophylaxis	CDC 57.206	Healthcare Worker Prophylaxis/Treatment
57.207_Follow-up Laboratory Testing	CDC 57.207	Follow-up Laboratory Testing
57.208_Healthcare Worker Vaccination History	CDC 57.208	Healthcare Worker Vaccination History
57.209_Healthcare Worker Influenza Vaccination	CDC Form 57.209	Healthcare Worker Influenza Vaccination
57.210_Healthcare Worker Influenza Antiviral Medication Administration	CDC 57.210	Healthcare Worker Prophylaxis/Treatment
57.211_Preseason Survey on Influenza Vaccination Program for Healthcare Personnel	CDC 57.211	Pre-season Survey on Influenza Vaccination Programs for Healthcare Personnel
57.212_Post-Season Survey on Influenza Vaccination Programs for Healthcare Personnel	CDC 57.212	Post-season Survey on Influenza Vaccination Programs for Healthcare Personnel
57.213_Healthcare Personnel Influenza Vaccination Monthly Summary	CDC 57.213	Healthcare Personnel Influenza Vaccination Monthly Summary
57.300_Hemovigilance Module Annual Survey	CDC 57.300	Hemovigilance Module Annual Facility Survey
57.301_Hemovigilance Module Monthly Reporting Plan	CDC 57.301	Hemovigilance Module Monthly Reporting Plan
57.302_Hemovigilance Module Blood Product Incident Reporting - Summary Data	CDC 57.302	Hemovigilance Module Monthly Incident Summary
57.303_Hemovigilance Module Monthly Reporting Denominators	CDC 57.303	hemovigilance Module Monthly Reporting Denominators
57.304_Hemovigilance Adverse Reaction	CDC 57.304	Hemovigilance Module Adverse Reaction
57.305_Hemovigilance Module Adverse Reaction	CDC 57.305	Hemovigilance Module Incident
Agreement to Participate and Consent	57.75T	Agreement to Participate and Consent
List of Blood Isolates	57.75CC	List of Blood Isolates
Manual Categorization of Positive Blood Cultures	57.75DD	Manual Categorization of Positive Cultures

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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: Changing Forms

Short Statement:

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Annual Cost to Federal Government: $7,451,954

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 04/14/2011

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