57.400 Outpatient Procedure - Annual Facility Survey

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⚠️ Notice: This information collection may be referencing outdated material.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 57.400 57.400 Outpatient Procedure - Annual Facility Survey Form
CDC 57.400 Outpatient Procedure Component - Annual Facility Survey 57.400_ASCFacSurv_BLANK.DOCX Form
CDC 57.400 Outpatient Procedure Component - Annual Facility Survey 57.400_ASCFacSurv_BLANK.DOCX Form
G17. Outpatient Procedure Component.pdf Att G17_Outpatient Procedure Component IC Document
G17. Outpatient Procedure Component.pdf Att G17_Outpatient Procedure Component IC Document

Information Collection (IC) Details

IC Title:	57.400 Outpatient Procedure - Annual Facility Survey	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 57.400	Outpatient Procedure Component - Annual Facility Survey	57.400_ASCFacSurv_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: 700	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	700	700
Annual IC Time Burden (Hours)	117	117
Annual IC Cost Burden (Dollars)	3,787	3,787

Documents for IC

Title	Document	Date Uploaded
Att G17_Outpatient Procedure Component	G17. Outpatient Procedure Component.pdf	08/08/2016

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