Healthcare Facility Assessment

Survey of Healthcare-Associated Infections and Antimicrobial Use in U.S. Nursing Homes for use in Exploring the Development of a National Prevalence Model

Documents and Forms

Document Name Document Type
Healthcare Facility Assessment Form and Instruction
Healthcare Facility Assessment (HFA) Form Att. C1 - Healthcare Facility Assessment (HFA)_Nursing Home.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Healthcare Facility Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	NA	Healthcare Facility Assessment (HFA) Form	Att. C1 - Healthcare Facility Assessment (HFA)_Nursing Home.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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