Information Collection

Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities

IC 249438 under ICR 202211-0920-014 · OMB 0920-1317.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1317 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	Form and Instruction
CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan 57.203_HCPSafetyPlan_July2021_FINAL.docx	Form and Instruction
CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan 57.203_HCPSafetyPlan_July2021_FINAL.docx	Form and Instruction

IC Title:

Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities

Agency IC Tracking Number:

0920-1317

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	CDC Form 57.203	Healthcare Personnel Safety Monthly Reporting Plan	57.203_HCPSafetyPlan_July2021_FINAL.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,700

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	69,300	69,300
Annual IC Time Burden (Hours)	5,775	5,775
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.