57.106 Patient Safety Monthly Reporting Plan

The National Healthcare Safety Network (NHSN)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 57.106 57.106 Patient Safety Monthly Reporting Plan Form
57.106 Patient Safety Monthly Reporting Plan 57.106_PSReportPlan_BLANK.DOCX Form
14. Reporting Plan (IC# 1).pdf Att G14 RP IC Document

Information Collection (IC) Details

IC Title:	57.106 Patient Safety Monthly Reporting Plan	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	57.106	Patient Safety Monthly Reporting Plan	57.106_PSReportPlan_BLANK.DOCX		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	72,000	62,000	10,000
Annual IC Time Burden (Hours)	42,000	-28,000	70,000
Annual IC Cost Burden (Dollars)	1,589,280	-1,116,220	2,705,500

Documents for IC

Title	Document	Date Uploaded
Att G14 RP	14. Reporting Plan (IC# 1).pdf	10/15/2012

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