Information Collection

57.104 NHSN Administrator Change Request Form

IC 237430 under ICR 202112-0920-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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
57.104 NHSN Administrator Change Request Form	Form and Instruction
Facility Administrator Change Request 57.104_FAChangeRequest_BLANK 020521 clean.docx	Form and Instruction
Facility Administrator Change Request 57.104_FAChangeRequest_BLANK 020521 clean.docx	Form and Instruction

IC Title:

57.104 NHSN Administrator Change Request Form

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 and Instruction	none	Facility Administrator Change Request	57.104_FAChangeRequest_BLANK 020521 clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 800

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	800	800
Annual IC Time Burden (Hours)	67	67
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.