Information Collection

57.122 HAI Progress Report State Health Department Survey

IC 233214 under ICR 202104-0920-002 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC 55.122 57.122 HAI Progress Report State Health Department Survey	Form
CDC 55.122 State Health Department HAI Mandate and Validatyion Surv 57.122_ State Health Department HAI Mandate and Validation Survey_BLANK.docx	Form
CDC 55.122 State Health Department HAI Mandate and Validatyion Surv 57.122_ State Health Department HAI Mandate and Validation Survey_BLANK.docx	Form

IC Title:

57.122 HAI Progress Report State Health Department 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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CDC 55.122	State Health Department HAI Mandate and Validatyion Survey	57.122_ State Health Department HAI Mandate and Validation Survey_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 55

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	55	55
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.