Information Collection

57.200 Healthcare Personnel Safety Component Facility Survey

IC 183582 under ICR 201112-0920-004 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.200 57.200 Healthcare Personnel Safety Component Facility Survey	Form
57.200 Healthcare Personnel Safety Component Annual Facility Su 57.200_AnnualFacSurv_BLANK.ppt	Form
6_HPS_toi.pdf 6_HPS_toi	IC Document

IC Title:

57.200 Healthcare Personnel Safety Component Facility Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.200	Healthcare Personnel Safety Component Annual Facility Survey	57.200_AnnualFacSurv_BLANK.ppt		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	48,000	48,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
6_HPS_toi	6_HPS_toi.pdf	12/05/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.