57.125 Central Line Insertion Practices Adherence Monitoring Form

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⚠️ Notice: This information collection may be referencing outdated material.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 57.125 57.125 Central Line Insertion Practices Adherence Monitoring Form Form
CDC 57.125 Central Line Insertion Practices Adherence Monitoring 57.125_CLIP_BLANK.docx Form
CDC 57.125 Central Line Insertion Practices Adherence Monitoring 57.125_CLIP_BLANK.docx Form
6. Central Line Insertion Practices (CLIP) Adherence.pdf Att G6_Central Line Insertion Practices Adherence IC Document
6. Central Line Insertion Practices (CLIP) Adherence.pdf Att G6_Central Line Insertion Practices Adherence IC Document

Information Collection (IC) Details

IC Title:	57.125 Central Line Insertion Practices Adherence Monitoring Form	Agency IC Tracking Number:

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 57.125	Central Line Insertion Practices Adherence Monitoring	57.125_CLIP_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: 500	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	106,500	106,500
Annual IC Time Burden (Hours)	44,375	44,375
Annual IC Cost Burden (Dollars)	1,759,912	1,759,912

Documents for IC

Title	Document	Date Uploaded
Att G6_Central Line Insertion Practices Adherence	6. Central Line Insertion Practices (CLIP) Adherence.pdf	09/24/2018

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