Information Collection

57.203 Healthcare Personnel Safety Reporting Plan

IC 183543 under ICR 201607-0920-013 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material.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
G12. Healthcare Personnel Exposure.pdf Att G12_Healthcare Personnel Exposure IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.203 Healthcare Personnel Safety Reporting Plan	Agency IC Tracking Number:	0920-0666

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: 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	17,000	17,000
Annual IC Time Burden (Hours)	1,417	1,417
Annual IC Cost Burden (Dollars)	112,918	112,918

Documents for IC

Title	Document	Date Uploaded
Att G12_Healthcare Personnel Exposure	G12. Healthcare Personnel Exposure.pdf	07/25/2016

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