The National Healthcare Safety Network (NHSN)

Forms and Documents

Document	Type	Status	Availability
Form CDC 57.106 57.106 Patient Safety Monthly Reporting Plan	Form and Instruction	Modified	Repair queued
Form CDC 57.154 CDC 57.154 Antimicrobial Use & Resistance Component - Monthly Reporting Plan	Form	New	Available
Form CDC 57.600 57.600 State Health Department Validation Record	Form	Modified	Available
Form CDC 57.506 57.506 Dialysis Patient Influenza Vaccination Denominator	Form	Modified	Available
Form CDC 57.505 57.505 Dialysis Patient Influenza Vaccination	Form	Modified	Available
Form CDC 57-504 57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Modified	Available
Form CDC 57.501 57.501 Dialysis Monthly Reporting Plan	Form	Modified	Repair queued
Form CDC 57.403 57.403 Outpatient Procedure - Monthly Denominators and Summary	Form	Modified	Repair queued
Form CDC 57.402 57.402 Outpatient Procedure - Event	Form	Modified	Available
Form CDC 57.401 57.401 Outpatient Procedure - Monthly Reporting Plan	Form	Modified	Available
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey	Form	Modified	Repair queued
Form CDC 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF	Form	Modified	Available
Form CDC 57.150 57.150 Patient Safety Component -- Annual Facility Survey for LTAC	Form	Modified	Repair queued
Form CDC 57.143 57.143 Prevention Process Measures Monthly Monitoring for LTCF	Form	Modified	Repair queued
Form CDC 57.142 57.142 Denominators for LTCF Locations	Form	Modified	Repair queued
Form CDC 57.141 57.141 Monthly Reporting Plan for LTCF	Form	Modified	Available
Form CDC 57.112 57.112 Ventilator-Associated Event (VAE)	Form	Modified	Repair queued
Form CDC 57.139 57.139 MDRO and CDI Monthly Monitoring for LTCF	Form	Modified	Repair queued
Form CDC 57.138 57.138 Laboratory-Identified MDRO or CDI Event for LTCF	Form	Modified	Repair queued
Form CDC 57.137 57.137 Long Term care Facility Component--Annual Facility Survey	Form	Modified	Repair queued
Form CDC 57.304 57.304 Hemovigilance Module Adverse Reaction	Form	Modified	Available
Form CDC 57.305 57.305 Hemovigilance Incident	Form	Modified	Repair queued
Form CDC 57.303 57.303 Hemovigilance Module Monthly Reporting Denominators	Form	Modified	Repair queued
Form CDC 57.301 57.301 Hemovigilance Module Monthly Reporting Plan	Form	Modified	Available
Form CDC 57.300 57.300 Hemovigilance Module Annual Facility Survey	Form	Modified	Available
Form CDC 57.200 57.200 Healthcare Personnel Safety Component Facility Survey	Form	Modified	Available
Form CDC 57.204 57.204 Healthcare Worker Demographic Data	Form	Modified	Available
Form CDC 57.206 57.206 Healthcare Worker Prophylaxis/Treatment	Form	Modified	Repair queued
Form CDC 57.205 57.205 Exposure to Blood and Body Fluids	Form	Modified	Repair queued
Form CDC 57.105 57.105 Group Contact Information	Form	Modified	Repair queued
Form CDC 57.140 57.140 Urinary Tract Infection (UTI) for LTCF	Form	Modified	Available
Form CDC 57.103 57.103 Patient Safety Component - Annual Hospital Survey	Form	Modified	Repair queued
Form 57.131 57.131 Vaccination Monthly Monitoring Form - Patient-Level Method	Form	Removed	Repair queued
Form CDC 57.101 57.101 Facility Contact Information	Form	Modified	Available
Form 57.133 57.133 Patient Vaccination	Form	Removed	Available
Form CDC 57.124 57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	Form and Instruction	Modified	Available
Form 57.130 57.130 Vaccination Monthly Monitoring Form - Summary Method	Form	Removed	Available
Form CDC 57.123 57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables	Form	Modified	Available
Form CDC 57.100 57.100 NHSN Registration Form	Form	Modified	Available
Form CDC 57.121 57.121 Denominators for Procedure	Form	Modified	Available
Form CDC 57.128 57.128 Laboratory Identified or CDI MDRO Event	Form	Modified	Repair queued
Form CDC 57.120 57.120 Surgical Site Infection (SSI)	Form	Modified	Repair queued
Form CDC 57.126 57.126 MDRO or CDI Infection Event	Form	Modified	Repair queued
Form CDC 57.503 57.503 Denominators for Outpatient Dialysis	Form and Instruction	Modified	Repair queued
Form CDC 57.127 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	Form	Modified	Available
Form CDC 57.118 57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)	Form	Modified	Repair queued
Form CDC 57.207 57.207 Follow-up Laboratory Testing	Form	Modified	Repair queued
Form CDC 57.117 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)	Form	Modified	Available
Form CDC 57.125 57.125 Central Line Insertion Practices Adherence Monitoring Form	Form	Modified	Repair queued
Form CDC 57.116 57.116 Denominators for Neonatal Intensive Care Unit (NICU)	Form	Modified	Repair queued
Form CDC 57.114 57.114 Urinary Tract Infection (UTI)	Form	Modified	Repair queued
Form CDC 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Form	Modified	Available
Form CDC 57.111 57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	Form	Modified	Repair queued
Form CDC 57.502 57.502 Dialysis Event	Form	Modified	Repair queued
Form CDC 57.108 57.108 Primary Bloodstream Infection (BSI)	Form	Modified	Repair queued
Form CDC 57.500 57.500 Outpatient Dialysis Center Practices Survey	Form and Instruction	Modified	Repair queued
Form CDC 57.203 57.203 Healthcare Personnel Safety Reporting Plan	Form	Modified	Repair queued
Att G.20_Ventilator Associated Pneumonia.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.19_Ventilator Associated Event.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.18. Surveys - Hospital, IRF, and LTAC.pdf	Supplementary Document	Uploaded 2014-09-10	Repair queued
Att G.17_Surgical Site Infection (SSI) Event.pdf	Supplementary Document	Uploaded 2014-09-10	Repair queued
Att G.16_State Validation Record.pdf	Supplementary Document	Uploaded 2014-09-10	Repair queued
Att G.15_Outpatient Procedure Component.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.14_MDRO CDI.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.13_LTCF UTI.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.12_ LTCF Prevention Process Measures.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.11_ LTCF MDRO CDI.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.10_Healthcare Personnel Exposure Module.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.9_Dialysis Prevention Process Measures.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.8_Dialysis Patient Influenza Vaccination.pdf	Supplementary Document	Uploaded 2014-09-10	Repair queued
Att G.7_Dialysis Event.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.6_Inst for Completion of Denominators (NICU).pdf	Supplementary Document	Uploaded 2014-09-10	Repair queued
Att G.5_CLIP Adherence Monitoring.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.4 CLABSI.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.3_Catheter-Associated UTI.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.2_ Biovigilance Component.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att G.1_Antimcrobial Use and Resistance.pdf	Supplementary Document	Uploaded 2014-09-10	Repair queued
Att E.4_Ambulatory Surgical Centers & Outpatient Acute Care Facility Departments - FLU.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att E.1_Acute Care & Long-Term Acute Care Hospitals - CLABSI, CAUTI, SSI, MDRO, FLU.pdf	Supplementary Document	Uploaded 2014-09-10	Available
Att D.4_Revision of Estimated Annual Cost Burden.docx	Supplementary Document	Uploaded 2014-09-10	Repair queued
Att D.3_Revision of Estimated Annual Burden Hours.docx	Supplementary Document	Uploaded 2014-09-10	Available
Att D.2_Itemized IC Revisions and Justifications.docx	Supplementary Document	Uploaded 2014-09-10	Available
Att D.1 Explanations and justifications for proposed revisions to OMB 0920-0666.docx	Supplementary Document	Uploaded 2014-09-10	Available
Att B_60d FRN.pdf	Supplementary Document	Uploaded 2014-09-10	Repair queued
Att F.1_IRB Protocol.docx	Supplementary Document	Uploaded 2014-09-10	Repair queued
SupSta Part B 0920-0666 _2014_REV.docx	Supporting Statement B	Uploaded 2014-09-09	Repair queued
2. NHSN - Report of End of Human Research Review 0.1253.docx	Supplementary Document	Uploaded 2013-08-21	Repair queued
2. NHSN 308d Approval Memo 2010.pdf	Supplementary Document	Uploaded 2013-08-21	Repair queued
1. NHSN 308d Approval 2010.pdf	Supplementary Document	Uploaded 2013-08-21	Available
3. NHSN 308d Request for Extension and Amendment.docx	Supplementary Document	Uploaded 2013-08-21	Repair queued
3. Dialysis Facilities - Dialysis Event.pdf	Supplementary Document	Uploaded 2013-08-21	Available
2. Inpatient Rehabilitation Facilities - CAUTI.PDF	Supplementary Document	Uploaded 2013-08-21	Available
3. 42 USC 242m.pdf	Supplementary Document	Uploaded 2013-08-21	Available
2. 42 USC 242k.pdf	Supplementary Document	Uploaded 2013-08-21	Repair queued
1. 42 USC 242b.pdf	Supplementary Document	Uploaded 2013-08-21	Available
0920-0666_SupSta A_Rev_09-22.docx	Supporting Statement A	Uploaded 2014-09-22	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
7134	57.106 Patient Safety Monthly Reporting Plan	Form and Instruction	Modified
212870	CDC 57.154 Antimicrobial Use & Resistance Component - Monthly Reporting Plan	Form	New
208412	57.600 State Health Department Validation Record	Form	Modified
208411	57.506 Dialysis Patient Influenza Vaccination Denominator	Form	Modified
208410	57.505 Dialysis Patient Influenza Vaccination	Form	Modified
208409	57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Modified
208408	57.501 Dialysis Monthly Reporting Plan	Form	Modified
208407	57.403 Outpatient Procedure - Monthly Denominators and Summary	Form	Modified
208406	57.402 Outpatient Procedure - Event	Form	Modified
208405	57.401 Outpatient Procedure - Monthly Reporting Plan	Form	Modified
208404	57.400 Outpatient Procedure - Annual Facility Survey	Form	Modified
200382	57.151 Patient Safety Component -- Annual Facility Survey for IRF	Form	Modified
200381	57.150 Patient Safety Component -- Annual Facility Survey for LTAC	Form	Modified
200380	57.143 Prevention Process Measures Monthly Monitoring for LTCF	Form	Modified
200379	57.142 Denominators for LTCF Locations	Form	Modified
200378	57.141 Monthly Reporting Plan for LTCF	Form	Modified
200377	57.112 Ventilator-Associated Event (VAE)	Form	Modified
197543	57.139 MDRO and CDI Monthly Monitoring for LTCF	Form	Modified
197542	57.138 Laboratory-Identified MDRO or CDI Event for LTCF	Form	Modified
197541	57.137 Long Term care Facility Component--Annual Facility Survey	Form	Modified
190365	57.304 Hemovigilance Module Adverse Reaction	Form	Modified
190364	57.305 Hemovigilance Incident	Form	Modified
190363	57.303 Hemovigilance Module Monthly Reporting Denominators	Form	Modified
190361	57.301 Hemovigilance Module Monthly Reporting Plan	Form	Modified
190360	57.300 Hemovigilance Module Annual Facility Survey	Form	Modified
183582	57.200 Healthcare Personnel Safety Component Facility Survey	Form	Modified
183579	57.204 Healthcare Worker Demographic Data	Form	Modified
183578	57.206 Healthcare Worker Prophylaxis/Treatment	Form	Modified
183577	57.205 Exposure to Blood and Body Fluids	Form	Modified
183576	57.105 Group Contact Information	Form	Modified
183573	57.140 Urinary Tract Infection (UTI) for LTCF	Form	Modified
183572	57.103 Patient Safety Component - Annual Hospital Survey	Form	Modified
183571	57.131 Vaccination Monthly Monitoring Form - Patient-Level Method	Form	Removed
183570	57.101 Facility Contact Information	Form	Modified
183569	57.133 Patient Vaccination	Form	Removed
183568	57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	Form and Instruction	Modified
183567	57.130 Vaccination Monthly Monitoring Form - Summary Method	Form	Removed
183566	57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables	Form	Modified
183565	57.100 NHSN Registration Form	Form	Modified
183564	57.121 Denominators for Procedure	Form	Modified
183563	57.128 Laboratory Identified or CDI MDRO Event	Form	Modified
183562	57.120 Surgical Site Infection (SSI)	Form	Modified
183561	57.126 MDRO or CDI Infection Event	Form	Modified
183560	57.503 Denominators for Outpatient Dialysis	Form and Instruction	Modified
183559	57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	Form	Modified
183558	57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)	Form	Modified
183557	57.207 Follow-up Laboratory Testing	Form	Modified
183556	57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)	Form	Modified
183555	57.125 Central Line Insertion Practices Adherence Monitoring Form	Form	Modified
183554	57.116 Denominators for Neonatal Intensive Care Unit (NICU)	Form	Modified
183551	57.114 Urinary Tract Infection (UTI)	Form	Modified
183550	57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Form	Modified
183549	57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	Form	Modified
183547	57.502 Dialysis Event	Form	Modified
183545	57.108 Primary Bloodstream Infection (BSI)	Form	Modified
183544	57.500 Outpatient Dialysis Center Practices Survey	Form and Instruction	Modified
183543	57.203 Healthcare Personnel Safety Reporting Plan	Form	Modified

ICR Details

OMB Control No: 0920-0666	ICR Reference No: 201407-0920-007
Status: Historical Active	Previous ICR Reference No: 201308-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No: 20352
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: 12/01/2014
	Date Received in OIRA: 09/23/2014
Terms of Clearance: The next ICR submission should include an explanation of what data are mandatory (and for whom) and what data are voluntary.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2017	36 Months From Approved	10/31/2016
Responses	8,975,750	0	8,810,700
Time Burden (Hours)	4,277,716	0	4,104,776
Cost Burden (Dollars)	141,057,383	0	138,604,613

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Abstract: NHSN is a system designed to accumulate, exchange, and integrate relevant information and resources among private and public stakeholders to support local and national efforts to protect patients and promote healthcare safety. The data are used to determine the magnitude of various healthcare-associated adverse events and trends in the rates of these events among patients and healthcare workers with similar risks,and to detect changes in the epidemiology of adverse events resulting from new and current medical therapies and changing risks. The NHSN has six components: Patient Safety, Healthcare Personnel Safety, Biovigilance,Long-Term Care Facility, Dialysis, and Outpatient Procedure.

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 35166	06/19/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 53199	09/08/2014
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
57.401 Outpatient Procedure - Monthly Reporting Plan	CDC 57.401	Outpatient Procedure Component Monthly Reporting Plan
57.402 Outpatient Procedure - Event	CDC 57.402	Outpatient Procedure - Event
57.403 Outpatient Procedure - Monthly Denominators and Summary	CDC 57.403	Outpatient Procedure - Monthly Denominators and Summary
57.501 Dialysis Monthly Reporting Plan	CDC 57.501	NHSN Registration Form
57.504 Prevention Process Measures Monthly Monitoring for Dialysis	CDC 57-504	Prevention Process Measures Monthly Monitoring for Dialysis
57.505 Dialysis Patient Influenza Vaccination	CDC 57.505	Dialysis Patient Influenza Vaccination
57.506 Dialysis Patient Influenza Vaccination Denominator	CDC 57.506	Dialysis Patient Influenza Vaccination Denominator
CDC 57.154 Antimicrobial Use & Resistance Component - Monthly Reporting Plan	CDC 57.154	Antimicrobial Use and Resistance Monthly Reporting Plan
57.112 Ventilator-Associated Event (VAE)	CDC 57.112	Ventilator-Associated Event (VAE)
57.600 State Health Department Validation Record	CDC 57.600	State Health Department Validation Record
57.106 Patient Safety Monthly Reporting Plan	CDC 57.106	Patient Safety Monthly Reporting Plan
57.203 Healthcare Personnel Safety Reporting Plan	CDC 57.203	Healthcare Personnel Safety Monthly Reporting Plan
57.500 Outpatient Dialysis Center Practices Survey	CDC 57.500	Outpatient Dialysis Center Practices Survey
57.108 Primary Bloodstream Infection (BSI)	CDC 57.108	Primary Bloodstreat Infection (BSI)
57.502 Dialysis Event	CDC 57.502	Dialysis Event
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	CDC 57.111	Pneumonia (PNEU)
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	CDC 57.210	HCW Prophylaxis/Treatment-Influenza
57.114 Urinary Tract Infection (UTI)	CDC 57.114	Urinary Tract Infection (UTI)
57.116 Denominators for Neonatal Intensive Care Unit (NICU)	CDC 57.116	Denominators for Neonatal intensive Care Unit (NICU)
57.125 Central Line Insertion Practices Adherence Monitoring Form	CDC 57.125	Central Line Insertion Practices Adherence Monitoring
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)	CDC 57.117	Denominators for Specialty Care Area (SCA) Oncology (ONC)
57.207 Follow-up Laboratory Testing	CDC 57.207	Follow-up Laboratory Testing
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)	CDC 57.118	Denominators for Intensive Care Unit (ICU)/Other Locations (not NICU or SCA)
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	CDC 57.127	MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting
57.141 Monthly Reporting Plan for LTCF	CDC 57.141	Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations	CDC 57.142	Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF	CDC 57.143	Prevention Process Measures Monthly Monitoring
57.150 Patient Safety Component -- Annual Facility Survey for LTAC	CDC 57.150	Patient Safety Component---Annual Facility Survey for LTAC
57.151 Patient Safety Component -- Annual Facility Survey for IRF	CDC 57.151	Patient Safety Component---Annual Facility Survey for IRF
57.400 Outpatient Procedure - Annual Facility Survey	CDC 57.400	Outpatient Procedure---Annual Facility Survey
57.100 NHSN Registration Form	CDC 57.100	NHSN Registration Form
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables	CDC 57.123	Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables
57.503 Denominators for Outpatient Dialysis	CDC 57.503	Denominators for Dialysis Event Surveillance (Census Form)
57.126 MDRO or CDI Infection Event	CDC 57.126	MDRO or CDI Infection Event
57.120 Surgical Site Infection (SSI)	CDC 57.120	Surgical Site Infection (SSI)
57.128 Laboratory Identified or CDI MDRO Event	CDC 57.128	Laboratory-identified MDRO or CDI Event
57.121 Denominators for Procedure	CDC 57.121	Denominator for Procedure
57.133 Patient Vaccination	57.133	Patient Vaccination
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	CDC 57.124	Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables
57.101 Facility Contact Information	CDC 57.101	Facility Contact Information
57.103 Patient Safety Component - Annual Hospital Survey	CDC 57.103	Patient Safety Component--Annual Hospital Survey
57.140 Urinary Tract Infection (UTI) for LTCF	CDC 57.140	Urinary Tract Infection (UTI) for LTCF
57.131 Vaccination Monthly Monitoring Form - Patient-Level Method	57.131	Vaccination Monthly Monitoring - Patient level
57.105 Group Contact Information	CDC 57.105	Group Contact Information
57.205 Exposure to Blood and Body Fluids	CDC 57.205	Exposure to Blood/Body Fluids
57.206 Healthcare Worker Prophylaxis/Treatment	CDC 57.206	Healthcare Worker Prophylaxis/Treatment
57.204 Healthcare Worker Demographic Data	CDC 57.204	Healthcare Worker Demographic Data
57.200 Healthcare Personnel Safety Component Facility Survey	CDC 57.200	Healthcare Personnel Safety - Annual Facility Survey
57.300 Hemovigilance Module Annual Facility Survey	CDC 57.300	Hemovigilance Module Annual Survey
57.301 Hemovigilance Module Monthly Reporting Plan	CDC 57.301	Hemovigilance Module Monthly Reporting Plan
57.303 Hemovigilance Module Monthly Reporting Denominators	CDC 57.303	Hemovigilance Module Monthly Reporting Denominators
57.305 Hemovigilance Incident	CDC 57.305	Hemovigilance Module Monthly Reporting Denominators
57.304 Hemovigilance Module Adverse Reaction	CDC 57.304	Hemovigilance Adverse Reaction
57.137 Long Term care Facility Component--Annual Facility Survey	CDC 57.137	Long Term Care Facility Component---Annual Facility Survey
57.138 Laboratory-Identified MDRO or CDI Event for LTCF	CDC 57.138	Laboratory-identified MDRO or CDI Event for LTCF
57.139 MDRO and CDI Monthly Monitoring for LTCF	CDC 57.139	MDRO and CDI Monthly Monitoring for LTCF
57.130 Vaccination Monthly Monitoring Form - Summary Method	57.130	Vaccination Monthly Monitoring - Summary Method

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ICR Summary 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	8,975,750	8,810,700	0	165,050	0	0
Annual Time Burden (Hours)	4,277,716	4,104,776	0	172,940	0	0
Annual Cost Burden (Dollars)	141,057,383	138,604,613	0	2,452,770	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Forms

Short Statement: This collection is currently approved for 8,810,700 responses and 4,104,776 burden hours. This revision request includes removing three forms, adding one form, and revisions to 31 previously approved forms. The reporting burden will increase by 172,943 hours, for a total estimated burden of 4,277,716 hours; annual cost of reporting would increase by $8,230,580.

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Annual Cost to Federal Government: $10,790,074

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

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Common Form ICR:  No

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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: 09/23/2014

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