57.203 Healthcare Personnel Safety Reporting Plan

The National Healthcare Safety Network (NHSN)

⚠️ Notice: This information collection may be referencing outdated material.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
CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan 57.203_HCPSafetyPlan_BLANK.docx Form
12. Healthcare Personnel Exposure.pdf Att G12_Healthcare Personnel Exposure IC Document
12. Healthcare Personnel Exposure.pdf Att G12_Healthcare Personnel Exposure IC Document

Information Collection (IC) Details

IC Title:	57.203 Healthcare Personnel Safety 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	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: 19,500	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	19,500	19,500
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	54,834	54,834

Documents for IC

Title	Document	Date Uploaded
Att G12_Healthcare Personnel Exposure	12. Healthcare Personnel Exposure.pdf	09/25/2018

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