The National Healthcare Safety Network (NHSN)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 57.106 Patient Safety Monthly Reporting Plan	Form	Modified	Available
Form 57.213 Healthcare Personnel Influenza Vaccination Monthly Summary	Form	Modified	Available
Form 57.303 Hemovigilance Module Monthly Reporting Denominators	Form	Modified	Available
Form 57.301 Hemovigilance Module Monthly Reporting Plan	Form	Modified	Available
Form 57.200 Healthcare Personnel Safety Component Annual Facility Survey	Form	Modified	Available
Form 57.208 Healthcare Worker Vaccination History	Form	Modified	Available
Form 57.204 Healthcare Worker Demographic Data	Form	Modified	Available
Form 57.205 Exposure to Blood/Body Fluids	Form	Modified	Available
Form 57.105 Group Contact Information	Form	Modified	Available
Form 57.101 Facility Contact Information	Form	Modified	Available
Form 57.124 Antimicrobial Use and Resistance (AUR)-Pharmacy Data Electronic Upload Specificaton Tables	Form	Modified	Available
Form 57.123 Antimicrobial Use and Resistance (AUR)-Microbiology Data Electronic Upload Specification Tables	Form	Modified	Available
Form 57.100 NHSN Registration Form	Form	Modified	Available
Form 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	Form	Modified	Available
Form 57.118 Denominator for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)	Form	Modified	Available
Form 57.207 Follow-up Laboratory Testing	Form	Modified	Available
Form 57.117 Denominators for Specialty Care Area (SCA)	Form	Modified	Available
Form 57.212 Post-season Survey on Influenza Vaccination Programs for Health Personnel	Form	Modified	Available
Form 57.210 Healthcare Worker Prophylaxis/Treatment Influenza	Form	Modified	Available
Form 57.111 Pneumonia (PNEU)	Form	Modified	Available
Form 57.209 Healthcare Worker Influenza Vaccinatuion	Form	Modified	Available
Form 57.104 Patient Safety Component--Outpatient Dialysis Center Practices Survey	Form	Modified	Source copy available
Form 57.203 Healthcare Personnel Safety Reporting Plan	Form	Modified	Available
Form 57.202 HealthCare Worker Survey	Form	Modified	Available
0920-0666 Revision September 2011 Supporting Statement Part B.docx	Supporting Statement B	Uploaded 2011-11-28	Available
E1. IRB Protocol.docx	Supplementary Document	Uploaded 2011-12-02	Available
D2. Itemized IC Revisions and Justifications.docx	Supplementary Document	Uploaded 2011-12-02	Available
D4. Revision of Estimated Annual Cost Burden.docx	Supplementary Document	Uploaded 2011-12-02	Available
D3. Revision of Estimated Annual Burden Hours.docx	Supplementary Document	Uploaded 2011-12-02	Available
E2. NHSN - Report of End of Human Research Review 0.1253.docx	Supplementary Document	Uploaded 2011-12-02	Available
D1. Explanations and justifications for proposed revisions to OMB 0920.docx	Supplementary Document	Uploaded 2011-12-02	Available
B. 60 day Federal Registry Notice.pdf	Supplementary Document	Uploaded 2011-11-30	Available
A2. 42 USC 242k.PDF	Supplementary Document	Uploaded 2011-11-28	Available
A1. 42 USC 242b.PDF	Supplementary Document	Uploaded 2011-11-28	Available
A3. 42 USC 242m.PDF	Supplementary Document	Uploaded 2011-11-28	Available
LTC TOI Prev Process Measures.docx	Supplementary Document	Uploaded 2011-12-05	Available
LTC Prev Process Measures Protocol.docx	Supplementary Document	Uploaded 2011-12-05	Available
F1.10PSC_PPP.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.6PSC_VAP.pdf	Supplementary Document	Uploaded 2011-12-05	Available
5_HPS_fluVacc.pdf	Supplementary Document	Uploaded 2011-12-05	Available
LTC MDRO CDI Protocol.docx	Supplementary Document	Uploaded 2011-12-05	Available
LTC TOI LAB ID EVENT.docx	Supplementary Document	Uploaded 2011-12-05	Available
LTC TOI Annual Facility Survey.docx	Supplementary Document	Uploaded 2011-12-05	Available
1-10-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
1-10-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
1-10-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
1-10-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
Appendix-G-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
Appendix-F-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
Appendix-E-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
Appendix-D-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
Appendix-C-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
Appendix-B-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
Appendix-A-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
1-10-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
1-10-BV-Protocol.pdf	Supplementary Document	Uploaded 2011-12-05	Available
6_HPS_toi.pdf	Supplementary Document	Uploaded 2011-12-05	Available
5_HPS_fluVacc.pdf	Supplementary Document	Uploaded 2011-12-05	Available
6_HPS_toi.pdf	Supplementary Document	Uploaded 2011-12-05	Available
5_HPS_fluVacc.pdf	Supplementary Document	Uploaded 2011-12-05	Available
4_HPS_bbfExpos.pdf	Supplementary Document	Uploaded 2011-12-05	Available
LTC UTI Protocol.docx	Supplementary Document	Uploaded 2011-12-05	Available
LTC TOI UTI.docx	Supplementary Document	Uploaded 2011-12-05	Available
F1.13PSC_HRIIV.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.13PSC_HRIIV.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.11PSC_AUR.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.13PSC_HRIIV.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.11PSC_AUR.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.17PSC_NosInfDef.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.16PSC_KeyTerms.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.15PSC_LocationsDescriptions.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.2PSC_IdentifyingHAIs_NHSN.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.1PSC_Overview.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.14PSC_Form_Instructions.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.12PSC_MDRO_CDAD.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.9PSC_SSI.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.12PSC_MDRO_CDAD.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.14PSC_Form_Instructions.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.12PSC_MDRO_CDAD.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.14PSC_Form_Instructions.pdf	Supplementary Document	Uploaded 2011-12-05	Available
5_HPS_fluVacc.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.14PSC_Form_Instructions.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.5PSC_CLIP.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.14PSC_Form_Instructions.pdf	Supplementary Document	Uploaded 2011-12-05	Available
5_HPS_fluVacc.pdf	Supplementary Document	Uploaded 2011-12-05	Available
5_HPS_fluVacc.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.7PSC_CAUTI.pdf	Supplementary Document	Uploaded 2011-12-05	Available
5_HPS_fluVacc.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.10PSC_PPP.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.6PSC_VAP.pdf	Supplementary Document	Uploaded 2011-12-05	Available
5_HPS_fluVacc.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.8PSC_DialysisEvent.pdf	Supplementary Document	Uploaded 2011-12-05	Available
F1.4PSC_CLABS.pdf	Supplementary Document	Uploaded 2011-12-05	Available
3_HPS_mrp.pdf	Supplementary Document	Uploaded 2011-12-05	Available
8_HPS_cdcCodes.pdf	Supplementary Document	Uploaded 2011-12-05	Available
7_HPS_keyTerms.pdf	Supplementary Document	Uploaded 2011-12-05	Available
2_HPS_intro.pdf	Supplementary Document	Uploaded 2011-12-05	Available
6_HPS_toi.pdf	Supplementary Document	Uploaded 2011-12-05	Available
0920-0666 Supporting Statement Part A 112111.docx	Supporting Statement A	Uploaded 2011-11-28	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
7134	57.106 Patient Safety Monthly Reporting Plan	Other-PDF	Modified
200382	57.151 Patient Safety Component -- Annual Facility Survey for IRF	Other-WORD	New
200381	57.150 Patient Safety Component -- Annual Facility Survey for LTAC	Other-WORD	New
200380	57.143 Prevention Process Measures Monthly Monitoring for LTCF	Other-WORD	New
200379	57.142 Denominators for LTCF Locations	Other-WORD	New
200378	57.141 Monthly Reporting Plan for LTCF	Other-WORD	New
200377	57.112 Streamlined Ventilator-Associated Pneumonia	Other-WORD	New
197544	57.213 Healthcare Personnel Influenza Vaccination Monthly Summary	Form	Modified	Healthcare Personnel Influenza Vaccination Monthly Summary
197543	57.139 MDRO and CDI Monthly Monitoring for LTCF	Other-WORD	Modified
197542	57.138 Laboratory-Identified MDRO or CDI Event for LTCF	Other-WORD	Modified
197541	57.137 Long Term care Facility Component--Annual Facility Survey	Other-WORD	Modified
190365	57.304 Hemovigilance Module Adverse Reaction	Other-WORD	Modified
190364	57.305 Hemovigilance Module Incident	Other-WORD	Modified
190363	57.303 Hemovigilance Module Monthly Reporting Denominators	Form	Modified	Hemovigilance Module Monthly Reporting Denominators
190362	57.302 Hemovigilance Module Monthly Incident Summary	Other-WORD	Modified
190361	57.301 Hemovigilance Module Monthly Reporting Plan	Form	Modified	Hemovigilance Module Monthly Reporting Plan
190360	57.300 Hemovigilance Module Annual Facility Survey	Other-WORD	Modified
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 Prophylaxis/Treatment	Other-WORD	Modified
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
183573	57.140 Urinary Tract Infection (UTI) for LTCF	Other-WORD	Modified
183572	57.103 Patient Safety Component Annual Facility Survey	Other-WORD	Modified
183571	57.131 Vaccination Monthly Monitoring Form - Patient-Level Method	Other-WORD	Modified
183570	57.101 Facility Contact Information	Form	Modified	Facility Contact Information
183569	57.133 Patient Vaccination	Other-WORD	Modified
183568	57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	Form	Modified	Antimicrobial Use and Resistance (AUR)-Pharmacy Data Electronic Upload Specificaton Tables
183567	57.130 Vaccination Monthly Monitoring Form - Summary Method	Other-WORD	Modified
183566	57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data	Form	Modified	Antimicrobial Use and Resistance (AUR)-Microbiology Data Electronic Upload Specification Tables
183565	57.100 NHSN Registration Form	Form	Modified	NHSN Registration Form
183564	57.121 Denominators for Procedure	Other-WORD	Modified
183563	57.128 Laboratory Identified or CDI MDRO Event	Other-WORD	Modified
183562	57.120 Surgical Site Infection (SSI)	Other-WORD	Modified
183561	57.126 MDRO or CDI Infection Event	Other-WORD	Modified
183560	57.119 Denominators for Outpatient Dialysis	Other-WORD	Modified
183559	57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	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	Denominator for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
183557	57.207 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	Other-WORD	Modified
183554	57.116 Denominators for Neonatal Intensive Care Unit (NICU)	Other-WORD	Modified
183553	57.212 Post-Season Survey on Influenza Vaccination Programs for Healthcare Personnel	Form	Modified	Post-season Survey on Influenza Vaccination Programs for Health Personnel
183552	57.211 Preseason Survey on Influenza Vaccination Program for Healthcare Personnel	Other-WORD	Modified
183551	57.114 Urinary Tract Infection (UTI)	Other-WORD	Modified
183550	57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Form	Modified	Healthcare Worker Prophylaxis/Treatment Influenza
183549	57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	Form	Modified	Pneumonia (PNEU)
183548	57.209 Healthcare Worker Influenza Vaccination	Form	Modified	Healthcare Worker Influenza Vaccinatuion
183547	57.109 Dialysis Event	Other-WORD	Modified
183545	57.108 Primary Bloodstream Infection (BSI)	Other-WORD	Modified
183544	57.104 Patient Safety Component --Outpatient Dialysis Center Practices Survey	Form	Modified	Patient Safety Component--Outpatient Dialysis Center Practices Survey
183543	57.203 Healthcare Personnel Safety Reporting Plan	Form	Modified	Healthcare Personnel Safety Reporting Plan
183542	57.202 Healthcare Worker Survey	Form	Modified	HealthCare Worker Survey

ICR Details

OMB Control No: 0920-0666	ICR Reference No: 201112-0920-004
Status: Historical Active	Previous ICR Reference No: 201105-0920-001
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: Approved without change	Conclusion Date: 01/16/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/08/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	36 Months From Approved	05/31/2014
Responses	9,672,750	0	8,809,350
Time Burden (Hours)	3,978,175	0	3,914,125
Cost Burden (Dollars)	162,000	0	162,000

---

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 request includes six new forms and small revisions to 20 previously approved forms. The reporting burden will increase by 64,050 hours, for a total estimated burden of 3, 978,175 hours; annual cost of reporting would increase by $4,781,769.

---

Authorizing Statute(s): US Code: 42 USC 242b Name of Law: Public Health Service Act
   US Code: 42 USC 242m Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: US Code: 42 USC 242k Name of Law: Public Health Service Ac t

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 177	09/13/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 74066	11/30/2011
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 54

table that charts list of burden

IC Title	Form No.	Form Name
57.100 NHSN Registration Form	57.100	NHSN Registration Form
57.101 Facility Contact Information	57.101	Facility Contact Information
57.103 Patient Safety Component Annual Facility Survey
57.104 Patient Safety Component --Outpatient Dialysis Center Practices Survey	57.104	Patient Safety Component--Outpatient Dialysis Center Practices Survey
57.105 Group Contact Information	57.105	Group Contact Information
57.106 Patient Safety Monthly Reporting Plan	57.106	Patient Safety Monthly Reporting Plan
57.108 Primary Bloodstream Infection (BSI)
57.109 Dialysis Event
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	57.111	Pneumonia (PNEU)
57.112 Streamlined Ventilator-Associated Pneumonia
57.114 Urinary Tract Infection (UTI)
57.116 Denominators for Neonatal Intensive Care Unit (NICU)
57.117 Denominators for Specialty Care Area (SCA)	57.117	Denominators for Specialty Care Area (SCA)
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (not NICU or SCA)	57.118	Denominator for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
57.119 Denominators for Outpatient Dialysis
57.120 Surgical Site Infection (SSI)
57.121 Denominators for Procedure
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data	57.123	Antimicrobial Use and Resistance (AUR)-Microbiology Data Electronic Upload Specification Tables
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	57.124	Antimicrobial Use and Resistance (AUR)-Pharmacy Data Electronic Upload Specificaton Tables
57.125 Central Line Insertion Practices Adherence Monitoring Form
57.126 MDRO or CDI Infection Event
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	57.127	MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring
57.128 Laboratory Identified or CDI MDRO Event
57.130 Vaccination Monthly Monitoring Form - Summary Method
57.131 Vaccination Monthly Monitoring Form - Patient-Level Method
57.133 Patient Vaccination
57.137 Long Term care Facility Component--Annual Facility Survey
57.138 Laboratory-Identified MDRO or CDI Event for LTCF
57.139 MDRO and CDI Monthly Monitoring for LTCF
57.140 Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations
57.143 Prevention Process Measures Monthly Monitoring for LTCF
57.150 Patient Safety Component -- Annual Facility Survey for LTAC
57.151 Patient Safety Component -- Annual Facility Survey for IRF
57.200 Healthcare Personnel Safety Component Facility Survey	57.200	Healthcare Personnel Safety Component Annual Facility Survey
57.202 Healthcare Worker Survey	57.202	HealthCare Worker Survey
57.203 Healthcare Personnel Safety Reporting Plan	57.203	Healthcare Personnel Safety Reporting Plan
57.204 Healthcare Worker Demographic Data	57.204	Healthcare Worker Demographic Data
57.205 Exposure to Blood and Body Fluids	57.205	Exposure to Blood/Body Fluids
57.206 Healthcare Worker Prophylaxis/Treatment
57.207 Laboratory Testing	57.207	Follow-up Laboratory Testing
57.208 Healthcare Worker Vaccination History	57.208	Healthcare Worker Vaccination History
57.209 Healthcare Worker Influenza Vaccination	57.209	Healthcare Worker Influenza Vaccinatuion
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	57.210	Healthcare Worker Prophylaxis/Treatment Influenza
57.211 Preseason Survey on Influenza Vaccination Program for Healthcare Personnel
57.212 Post-Season Survey on Influenza Vaccination Programs for Healthcare Personnel	57.212	Post-season Survey on Influenza Vaccination Programs for Health Personnel
57.213 Healthcare Personnel Influenza Vaccination Monthly Summary	57.213	Healthcare Personnel Influenza Vaccination Monthly Summary
57.300 Hemovigilance Module Annual Facility Survey
57.301 Hemovigilance Module Monthly Reporting Plan	57.301	Hemovigilance Module Monthly Reporting Plan
57.302 Hemovigilance Module Monthly Incident Summary
57.303 Hemovigilance Module Monthly Reporting Denominators	57.303	Hemovigilance Module Monthly Reporting Denominators
57.304 Hemovigilance Module Adverse Reaction
57.305 Hemovigilance Module Incident

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	9,672,750	8,809,350	1,363,400	0	-500,000	0
Annual Time Burden (Hours)	3,978,175	3,914,125	106,242	0	-42,192	0
Annual Cost Burden (Dollars)	162,000	162,000	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Twenty data collection tools previously approved under OMB No. 0920-0666 have been revised in this revision request. In addition, six new forms are being submitted for approval.

---

Annual Cost to Federal Government: $8,673,111

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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

---

Common Form ICR:  No

---

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: 12/08/2011

---