Document
Healthcare Personnel Safety - Annual Facility Survey
ICR 201808-0920-011 · OMB 0920-0666 · Object 85392401.
This document may belong to an older filing. More recent activity for OMB 0920-0666:
Document Viewer [docx]
Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Healthcare Personnel Safety - Annual Facility Survey |
| Author | Amy Schneider |
| Last Modified By | Writer |
| File Modified | 2013-06-11 |
| File Created | 2026-10-30 |
| Conversion State | complete |
Extracted Text
Healthcare Personnel Safety Component— Annual Facility Survey Page 1 of 2 *required for saving Tracking #: ____________________________ Facility ID#: _________________________ *Survey Year: ___________ *Facility Information *Number of: Total beds set up and staffed Patient admissions Inpatient days Outpatient encounters Number of hours worked by all employees (from OSHA 300 log) Enter Selected Healthcare Worker Occupational Groups on page 2. Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 8 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.200 (Front), v6.6 Healthcare Personnel Safety Component— Annual Facility Survey Page 2 of 2 *Selected Healthcare Worker Occupational Groups Occupation Number of HCWs Number of FTEs Registered nurse Licensed practical nurse Nurse practitioner/clinical nurse specialist Nurse assistant/patient care technician Nurse midwife Nurse anesthetist Attendant/orderly Respiratory technician/therapist Phlebotomist IV team Medical laboratory technician OR/surgical technician Dental assistant/technician Dental hygienist Dentist Housekeeper Laundry staff Maintenance/engineering service Central supply staff Physician assistants Intern/resident Fellow Attending physician