57.129_Adult Sepsis_BLANK

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⚠️ Notice: This information collection may be referencing outdated material.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 57.129 57.129_Adult Sepsis_BLANK Form
57.129 Adult Sepsis_ 57.129_Adult Sepsis_BLANK.docx Form
57.129 Adult Sepsis_ 57.129_Adult Sepsis_BLANK.docx Form

Information Collection (IC) Details

IC Title:	57.129_Adult Sepsis_BLANK	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	57.129	Adult Sepsis_	57.129_Adult Sepsis_BLANK.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	12,500	12,500
Annual IC Time Burden (Hours)	5,208	5,208
Annual IC Cost Burden (Dollars)	206,562	206,562

Documents for IC

Title	Document	Date Uploaded
No associated records found

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