Information Collection

57.200 Healthcare Personnel Safety Component Facility Survey

IC 183582 under ICR 201407-0920-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 CDC 57.200 57.200 Healthcare Personnel Safety Component Facility Survey	Form
CDC 57.200 Healthcare Personnel Safety - Annual Facility Survey 57.200_AnnualFacSurv_BLANK.DOCX	Form
Att G.10_Healthcare Personnel Exposure Module.pdf NHSN healthcare Personnel Safety Component Protocol: Healthcare Personnel Exposure Module	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	CDC 57.200	Healthcare Personnel Safety - Annual Facility Survey	57.200_AnnualFacSurv_BLANK.DOCX		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	15,940	15,940

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NHSN healthcare Personnel Safety Component Protocol: Healthcare Personnel Exposure Module	Att G.10_Healthcare Personnel Exposure Module.pdf	08/28/2014

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