57.140 Urinary Tract Infection (UTI) for LTCF

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⚠️ Notice: This information collection may be referencing outdated material.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 57.140 57.140 Urinary Tract Infection (UTI) for LTCF Form
CDC 57.140 Urinary Tract Infection (UTI) for LTCF 57.140_UTI_LTCF_BLANK.docx Form
CDC 57.140 Urinary Tract Infection (UTI) for LTCF 57.140_UTI_LTCF_BLANK.docx Form
15. LTCF Urinary Tract Infection.pdf Att G15_LTCF Urinary Tract Infection IC Document
15. LTCF Urinary Tract Infection.pdf Att G15_LTCF Urinary Tract Infection IC Document

Information Collection (IC) Details

IC Title:	57.140 Urinary Tract Infection (UTI) for LTCF	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 57.140	Urinary Tract Infection (UTI) for LTCF	57.140_UTI_LTCF_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: 339	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	12,204	12,204
Annual IC Time Burden (Hours)	7,119	7,119
Annual IC Cost Burden (Dollars)	282,340	282,340

Documents for IC

Title	Document	Date Uploaded
Att G15_LTCF Urinary Tract Infection	15. LTCF Urinary Tract Infection.pdf	09/26/2018

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