Information Collection

57.106 Patient Safety Monthly Reporting Plan

IC 7134 under ICR 201908-0920-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.106 57.106 Patient Safety Monthly Reporting Plan Form and Instruction
CDC 57.106 Patient Safety Monthly Reporting Plan 57.106_PS ReportPlan_BLANK.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.106 Patient Safety Monthly Reporting Plan	Agency IC Tracking Number:	0920-0666

Is this a Common Form? No		IC Status: Unchanged

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	CDC 57.106	Patient Safety Monthly Reporting Plan	57.106_PS ReportPlan_BLANK.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,000	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	Previously Approved
Annual Number of Responses for this IC	72,000	72,000
Annual IC Time Burden (Hours)	18,000	18,000
Annual IC Cost Burden (Dollars)	713,880	713,880

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.