Information Collection

Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation

IC 231482 under ICR 202004-0938-008 · OMB 0938-1352.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1352 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10668 Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation	Form and Instruction
CMS-10668 Cauti Validation Template FY22_CAUTI_ValTemp_3_4Q_021720.xlsx	Form and Instruction
CMS-10668 CDI Validation Template FY22_CDI_ValTemp_3_4Q_021720.xlsx	Form and Instruction
CMS-10668 CLABSI Validation Template FY22_CLABSI_ValTemp_3_4Q_021720.xlsx	Form and Instruction
CMS-10668 MRSA Validation Template FY22_MRSA_ValTemp_3_4Q_021720.xlsx	Form and Instruction
Cohort 2 Catchement Area ZIP Code Crosswalk (1).xlsx Zipcode Crosswalk	IC Document

IC Title:

Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10668	Cauti Validation Template	FY22_CAUTI_ValTemp_3_4Q_021720.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10668	CDI Validation Template	FY22_CDI_ValTemp_3_4Q_021720.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10668	CLABSI Validation Template	FY22_CLABSI_ValTemp_3_4Q_021720.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10668	MRSA Validation Template	FY22_MRSA_ValTemp_3_4Q_021720.xlsx	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: 222

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	400	-200	600
Annual IC Time Burden (Hours)	28,800	-14,400	43,200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Zipcode Crosswalk	Cohort 2 Catchement Area ZIP Code Crosswalk (1).xlsx	05/01/2020

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