Information Collection

57.150 Patient Safety Component -- Annual Facility Survey for LTAC

IC 200381 under ICR 201708-0920-029 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.150 57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form
CDC 57.150 LTAC Annual Survey 57.150_LTACFacSurv_BLANK.DOCX Form
G19. Sepsis.pdf Att G19_Sepsis IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.150 Patient Safety Component -- Annual Facility Survey for LTAC	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 57.150	LTAC Annual Survey	57.150_LTACFacSurv_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: 400	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	400	0	400
Annual IC Time Burden (Hours)	400	33	367
Annual IC Cost Burden (Dollars)	15,864	8,296	7,568

Documents for IC

Title	Document	Date Uploaded
Att G19_Sepsis	G19. Sepsis.pdf	08/08/2016

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