57.137 Long Term care Facility Component--Annual Facility Survey

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⚠️ Notice: This information collection may be referencing outdated material.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 CDC 57.137 57.137 Long Term care Facility Component--Annual Facility Survey Form
CDC 57.137 Long Term Care Facility Component---Annual Facility Surv 57.137_LTCFSurv_BLANK.docx Form
Att G.12_ LTCF Prevention Process Measures.pdf Att G.12_Prevention Process Measures Surveillance for Long term Care Facilities IC Document

Information Collection (IC) Details

IC Title:	57.137 Long Term care Facility Component--Annual Facility Survey	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	CDC 57.137	Long Term Care Facility Component---Annual Facility Survey	57.137_LTCFSurv_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: 250	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	250	0	250
Annual IC Time Burden (Hours)	250	62	188
Annual IC Cost Burden (Dollars)	7,095	0	7,095

Documents for IC

Title	Document	Date Uploaded
Att G.12_Prevention Process Measures Surveillance for Long term Care Facilities	Att G.12_ LTCF Prevention Process Measures.pdf	08/28/2014

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