57.143 Prevention Process Measures Monthly Monitoring for LTCF

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⚠️ Notice: This information collection may be referencing outdated material.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 57.143 57.143 Prevention Process Measures Monthly Monitoring for LTCF Form
CDC 57.143 Prevention Process Measures Monthly Monitoring 57.143_ProcessMeasureSummaryforLTCF_BLANK.DOCX Form
Att G13_LTCF Prevention Process Measures.pdf Att G13_LTCF Prevention Process Measures IC Document

Information Collection (IC) Details

IC Title:	57.143 Prevention Process Measures Monthly Monitoring for LTCF	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 57.143	Prevention Process Measures Monthly Monitoring	57.143_ProcessMeasureSummaryforLTCF_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: 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	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	9,460	9,460

Documents for IC

Title	Document	Date Uploaded
Att G13_LTCF Prevention Process Measures	Att G13_LTCF Prevention Process Measures.pdf	09/09/2015

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