57.122 HAI Progress Report State Health Department 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⚠️ Notice: This information collection may be referencing outdated material.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 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

Information Collection (IC) Details

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:

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 %

	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

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.