The National Healthcare Safety Network (NHSN)

Forms and Documents

Document Name	Status
Form CDC 57.106 57.106 Patient Safety Monthly Reporting Plan Form and Instruction	Unchanged
Form CDC 57.506 57.506 Dialysis Patient Influenza Vaccination Denominator Form	Unchanged
Form CDC 57.505 57.505 Dialysis Patient Influenza Vaccination Form	Unchanged
Form CDC 57.504 57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form	Unchanged
Form CDC 57.501 57.501 Dialysis Monthly Reporting Plan Form	Unchanged
Form CDC 57.403 57.403 Outpatient Procedure - Monthly Denominators and Summary Form	Unchanged
Form CDC 57.402 57.402 Outpatient Procedure - Event Form	Unchanged
Form CDC 57.401 57.401 Outpatient Procedure - Monthly Reporting Plan Form	Unchanged
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey Form	Unchanged
Form CDC 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form	Unchanged
Form CDC 57.150 57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form	Unchanged
Form CDC 57.143 57.143 Prevention Process Measures Monthly Monitoring for LTCF Form	Unchanged
Form CDC 57.142 57.142 Denominators for LTCF Locations Form	Unchanged
Form CDC 57.141 57.141 Monthly Reporting Plan for LTCF Form	Unchanged
Form CDC 57.112 57.112 Ventilator-Associated Event (VAE) Form	Unchanged
Form CDC 57.139 57.139 MDRO and CDI Monthly Monitoring for LTCF Form	Unchanged
Form CDC 57.138 57.138 Laboratory-Identified MDRO or CDI Event for LTCF Form	Unchanged
Form CDC 57.137 57.137 Long Term care Facility Component--Annual Facility Survey Form	Unchanged
Form CDC 57.304 57.304 Hemovigilance Module Adverse Reaction Form	Unchanged
Form CDC 57.305 57.305 Hemovigilance Incident Form	Unchanged
Form CDC 57.303 57.303 Hemovigilance Module Monthly Reporting Denominators Form	Modified
Form CDC 57.301 57.301 Hemovigilance Module Monthly Reporting Plan Form	Unchanged
Form CDC 57.300 57.300 Hemovigilance Module Annual Facility Survey Form	Unchanged
Form CDC 57.200 57.200 Healthcare Personnel Safety Component Facility Survey Form	Unchanged
Form CDC 57.204 57.204 Healthcare Worker Demographic Data Form	Unchanged
Form CDC 57.206 57.206 Healthcare Worker Prophylaxis/Treatment Form	Unchanged
Form CDC 57.205 57.205 Exposure to Blood and Body Fluids Form	Unchanged
Form CDC 57.105 57.105 Group Contact Information Form	Unchanged
Form CDC 57.140 57.140 Urinary Tract Infection (UTI) for LTCF Form	Unchanged
Form CDC 57.103 57.103 Patient Safety Component - Annual Hospital Survey Form	Unchanged
Form CDC 57.101 57.101 Facility Contact Information Form	Unchanged
Form CDC 57.124 57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Form	Unchanged
Form CDC 57.123 57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Form	Unchanged
Form CDC 57.100 57.100 NHSN Registration Form Form	Unchanged
Form CDC 57.121 57.121 Denominators for Procedure Form	Unchanged
Form CDC 57.128 57.128 Laboratory Identified or CDI MDRO Event Form	Unchanged
Form CDC 57.120 57.120 Surgical Site Infection (SSI) Form	Unchanged
Form CDC 57.126 57.126 MDRO or CDI Infection Event Form	Unchanged
Form CDC 57.503 57.503 Denominators for Outpatient Dialysis Form	Unchanged
Form CDC 57.127 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form	Unchanged
Form CDC 57.118 57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Form	Unchanged
Form CDC 57.207 57.207 Follow-up Laboratory Testing Form	Unchanged
Form CDC 57.117 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form	Unchanged
Form CDC 57.125 57.125 Central Line Insertion Practices Adherence Monitoring Form Form	Unchanged
Form CDC 57.116 57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form	Unchanged
Form CDC 57.114 57.114 Urinary Tract Infection (UTI) Form	Unchanged
Form CDC 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form	Unchanged
Form CDC 57.111 57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Form	Unchanged
Form CDC 57.502 57.502 Dialysis Event Form	Unchanged
Form CDC 57.108 57.108 Primary Bloodstream Infection (BSI) Form	Unchanged
Form CDC 57.500 57.500 Outpatient Dialysis Center Practices Survey Form and Instruction	Unchanged
Form CDC 57.203 57.203 Healthcare Personnel Safety Reporting Plan Form	Unchanged
0920-0666 Non-sub change request.docx Justification for No Material/Nonsubstantive Change	2016-03-16
Att D-2. Itemized IC Revisions and Justifications.docx Supplementary Document	2015-12-24
Att H3_NHSN 308d Request for Extension and Amendment.docx Supplementary Document	2015-09-09
Att H2_NHSN 308d Approval Memo 2010.pdf Supplementary Document	2015-09-09
Att H1_NHSN 308d Approval 2010.pdf Supplementary Document	2015-09-09
Att F2_NHSN - Report of End of Human Research Review 0.1253.docx Supplementary Document	2015-09-08
Att F1_Closure of Protocol.msg Supplementary Document	2015-09-08
Att E6_Inpatient Psychiatric Facilities - FLU.PDF Supplementary Document	2015-09-08
Att E5_Ambulatory Surgical Centers & Outpatient Acute Care Facility Departme....pdf Supplementary Document	2015-09-08
Att E4_Dialysis Facilities - Dialysis Event, FLU.PDF Supplementary Document	2015-09-08
Att E3_Inpatient Rehabiliation Facilities - CAUTI, LabID, FLU.PDF Supplementary Document	2015-09-08
Att E2_Acute Care Facility.pdf Supplementary Document	2015-09-08
Att E1_NHSN Forms used for CMS QRPs & State Mandated Reporting.docx Supplementary Document	2015-09-08
Att D-4. Revision of Estimated Annual Cost Burden.docx Supplementary Document	2015-12-24
Att D-3. Revision of Estimated Annual Burden Hours.docx Supplementary Document	2015-12-24
2. Itemized IC Revisions and Justifications.docx Supplementary Document	2015-09-08
D1. Explanations and justifications for proposed revisions to OMB 0920-0666.docx Supplementary Document	2015-09-08
Att B - 60 day.pdf Supplementary Document	2015-08-31
0920-0666_Rev_SupSta Part B.docx Supporting Statement B	2015-08-31
3. 42 USC 242m.pdf Supplementary Document	2013-08-21
2. 42 USC 242k.pdf Supplementary Document	2013-08-21
1. 42 USC 242b.pdf Supplementary Document	2013-08-21
0920-0666_Rev Decr2015 SupSta A.docx Supporting Statement A	2015-12-24

IC Document Collections

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

ICR Details

OMB Control No: 0920-0666	ICR Reference No: 201603-0920-007
Status: Historical Active	Previous ICR Reference No: 201508-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 16VD
Title: The National Healthcare Safety Network (NHSN)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/17/2016
	Date Received in OIRA: 03/16/2016
Terms of Clearance: CDC is approved to proceed with this collection and will coordinate future amendments to the collection instruments with CMS and other agencies/groups that require mandatory reporting of NHSN-collected data.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2018	12/31/2018	12/31/2018
Responses	9,007,950	0	9,007,950
Time Burden (Hours)	4,622,542	0	4,621,542
Cost Burden (Dollars)	146,685,095	0	146,685,095

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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 NHSN has six components: Patient Safety, Healthcare Personnel Safety, Biovigilance,Long-Term Care Facility, Dialysis, and Outpatient Procedure. The Non-Substantive Changes include the addition of pathogen reduced blood product categories for red blood cells, platelets, plasma, and cryoprecipitate, as well as data collected to include a breakdown of pathogen reduced apheresis platelets in plasma and in platelet additive solution.

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Authorizing Statute(s): 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
   US Code: 42 USC 242k 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:
	80 FR 37265	06/30/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 53797	09/08/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 52

IC Title	Form No.	Form Name
57.151 Patient Safety Component -- Annual Facility Survey for IRF	CDC 57.151	Patient Safetu Component--Annual Faciluity Survey for IRF
57.400 Outpatient Procedure - Annual Facility Survey	CDC 57.400	Patient Safety Component---Annual Facility Survey for Ambulatory Surgery Center (ASC)
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
57.401 Outpatient Procedure - Monthly Reporting Plan	CDC 57.401	Outpatient Procedure Component Monthly Reporting Plan
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
57.106 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
57.503 Denominators for Outpatient Dialysis	CDC 57.503	Demominators for Dialysis Event Surveillance
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, CDC 57.128 Rev 7, v8.5	Laboratory-identified MDRO or CDI Event ,   Lab ID Event
57.121 Denominators for Procedure	CDC 57.121	Denominatoir for Procedure
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
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	CDC 57.124	Antimicrobial Use and Resistance (AUR): Pharmacy Date Monthly Electronice 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
57.105 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 Facility 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 Incident
57.304 Hemovigilance Module Adverse Reaction	CDC 57.304	Hemovigilance Module 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
57.112 Ventilator-Associated Event (VAE)	CDC 57.112	Ventilator-Associated Event (VAE)
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 Faciity Survey for LTAC
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

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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	9,007,950	9,007,950	0	0	0	0
Annual Time Burden (Hours)	4,622,542	4,621,542	0	1,000	0	0
Annual Cost Burden (Dollars)	146,685,095	146,685,095	0	0	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: No

Burden Reduction Due to:

Short Statement: Non-Substantive Change resulted in a modification to Form CDC 57.303 and a slight increase in overall Burden Hours.

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Annual Cost to Federal Government: $12,842,487

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: 03/16/2016

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