57.203 Healthcare Personnel Safety 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⚠️ Notice: This information collection may be referencing outdated material.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 CDC 57.203 57.203 Healthcare Personnel Safety Reporting Plan Form
CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan 57.203_HCPSafetyPlan_BLANK.DOCX Form
Att G11_Healthcare Personnel Exposure.pdf Att G11_Healthcare Personnel Exposure IC Document

Information Collection (IC) Details

IC Title:	57.203 Healthcare Personnel Safety 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	CDC 57.203	Healthcare Personnel Safety Monthly Reporting Plan	57.203_HCPSafetyPlan_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: 17,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	17,000	6,000	11,000
Annual IC Time Burden (Hours)	1,417	500	917
Annual IC Cost Burden (Dollars)	112,918	39,854	73,064

Documents for IC

Title	Document	Date Uploaded
Att G11_Healthcare Personnel Exposure	Att G11_Healthcare Personnel Exposure.pdf	09/08/2015

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