Primary Team/ EIP Team Data Collection Form

Prevalence Survey of Healthcare Associated Infections (HAIs) and Antimicrobial Use in U.S. Acute Care Hospitals

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0852 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0852 Primary Team/ EIP Team Data Collection Form Form and Instruction
0920-0852 AttachmentC_0920-0852_OMBApprovedDataCollectionForm AttachmentC_0920-0852_OMBApprovedDataCollectionForm_FINAL_20121108.docx Form and Instruction
AttachmentF_0920-0852_SupplementalInformationOnly_FINAL_20121108.docx AttachmentF_0920-0852_SupplementalInformationOnly IC Document

Information Collection (IC) Details

IC Title:	Primary Team/ EIP Team Data Collection Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0852	AttachmentC_0920-0852_OMBApprovedDataCollectionForm	AttachmentC_0920-0852_OMBApprovedDataCollectionForm_FINAL_20121108.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	37,500	1,000	36,500
Annual IC Time Burden (Hours)	7,500	200	7,300
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
AttachmentF_0920-0852_SupplementalInformationOnly	AttachmentF_0920-0852_SupplementalInformationOnly_FINAL_20121108.docx	02/27/2013

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