Information Collection

57.200 Healthcare Personnel Safety Component Facility Survey

IC 183582 under ICR 201211-0920-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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
57.200_AnnualFacSurv_BLANK.docx	Other-WORD
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
Other-WORD			57.200_AnnualFacSurv_BLANK.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	100	-5,900	6,000
Annual IC Time Burden (Hours)	800	-47,200	48,000
Annual IC Cost Burden (Dollars)	31,752	31,752	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.