OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

[NCEZID] The National Healthcare Safety Network (NHSN)

ICR 202212-0920-013 · OMB 0920-0666 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form 57.106 57.106 Patient Safety Monthly Reporting Plan Form and Instruction Modified Repair queued
Form 57.106 57.106 Patient Safety Monthly Reporting Plan Form and Instruction Modified Repair queued
Monthly Survey Patient Days & Nurse Staffing Form and Instruction New Available
Monthly Survey Patient Days & Nurse Staffing Form and Instruction New Repair queued
Form 0920-0666 Annual Healthcare Personnel Influenza Vaccination Summary Form and Instruction Unchanged Available
Form 0920-0666 Annual Healthcare Personnel Influenza Vaccination Summary Form and Instruction Unchanged Repair queued
Form 0920-0666 Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Unchanged Repair queued
Form 0920-0666 Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Unchanged Repair queued
Form 0920-0666 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Unchanged Repair queued
Form 0920-0666 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Unchanged Repair queued
Form 0920-0666 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities Form and Instruction Unchanged Repair queued
Form 0920-0666 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities Form and Instruction Unchanged Repair queued
Form 57.135 57.135 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) Form and Instruction Unchanged Repair queued
Form 57.135 57.135 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) Form and Instruction Unchanged Repair queued
Form 57.136 57.136 Long Term Care Facility Component - Respiratory Tract Infection Form and Instruction Unchanged Repair queued
Form 57.136 57.136 Long Term Care Facility Component - Respiratory Tract Infection Form and Instruction Unchanged Missing upstream
57.104 NHSN Administrator Change Request Form Form and Instruction Unchanged Repair queued
57.104 NHSN Administrator Change Request Form Form and Instruction Unchanged Repair queued
Form CDC 55.122 57.122 HAI Progress Report State Health Department Survey Form Unchanged Repair queued
Form CDC 55.122 57.122 HAI Progress Report State Health Department Survey Form Unchanged Repair queued
Form 57.404 57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Form Unchanged Repair queued
Form 57.404 57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Form Unchanged Repair queued
Form 57.404 57.404 Outpatient Procedure Component - SSI Denominators Form Unchanged Available
Form 57.404 57.404 Outpatient Procedure Component - SSI Denominators Form Unchanged Repair queued
Form 57.507 57.507_HomeDialysisSurv Form Unchanged Available
Form 57.507 57.507_HomeDialysisSurv Form Unchanged Repair queued
Form 57.320 57.320_HV AR-Other_BLANK Form Unchanged Repair queued
Form 57.320 57.320_HV AR-Other_BLANK Form Unchanged Repair queued
Form CDC 57.319 57.319_HV AR-UNK_BLANK Form Unchanged Repair queued
Form CDC 57.319 57.319_HV AR-UNK_BLANK Form Unchanged Repair queued
Form 57.318 57.318_HV AR-TACO_BLANK Form Unchanged Available
Form 57.318 57.318_HV AR-TACO_BLANK Form Unchanged Repair queued
Form 57.317 57.317_HV AR-TRALI_BLAN Form Unchanged Available
Form 57.317 57.317_HV AR-TRALI_BLAN Form Unchanged Missing upstream
Form CDC 57.316 57.316_HV AR-TAGVHD_BLAN Form Unchanged Available
Form CDC 57.316 57.316_HV AR-TAGVHD_BLAN Form Unchanged Repair queued
Form CDC 57.315 57.315_HV AR-TAD_BLAN Form Unchanged Repair queued
Form CDC 57.315 57.315_HV AR-TAD_BLAN Form Unchanged Repair queued
Form 57.314 57.314_HV AR-PTP_BLAN Form Unchanged Repair queued
Form 57.314 57.314_HV AR-PTP_BLAN Form Unchanged Repair queued
Form 57.313 57.313_HV AR-Infection_BLAN Form Unchanged Repair queued
Form 57.313 57.313_HV AR-Infection_BLAN Form Unchanged Repair queued
Form 57.312 57.312_HV AR-HTR_BLANK Form Unchanged Available
Form 57.312 57.312_HV AR-HTR_BLANK Form Unchanged Repair queued
Form CDC 57.311 57.311_HV AR-FNHTR_BLANK Form Unchanged Available
Form CDC 57.311 57.311_HV AR-FNHTR_BLANK Form Unchanged Repair queued
Form 57.310 57.310_HV AR-DSTR_BLANK Form Unchanged Repair queued
Form 57.310 57.310_HV AR-DSTR_BLANK Form Unchanged Repair queued
Form CDC 57.309 57.309_HV AR-DHTR_BLANK Form Unchanged Available
Form CDC 57.309 57.309_HV AR-DHTR_BLANK Form Unchanged Missing upstream
Form 57.308 57.308_HV AR-Allergic_BLANK Form Unchanged Repair queued
Form 57.308 57.308_HV AR-Allergic_BLANK Form Unchanged Repair queued
Form 57.307 57.307_HV AR-AHTR_BLANK Form Unchanged Repair queued
Form 57.307 57.307_HV AR-AHTR_BLANK Form Unchanged Repair queued
Form 57.306 57.306_HV Annual Facility Sur Form Unchanged Available
Form 57.306 57.306_HV Annual Facility Sur Form Unchanged Missing upstream
Form 57.129 57.129_Adult Sepsis_BLANK Form Unchanged Repair queued
Form 57.129 57.129_Adult Sepsis_BLANK Form Unchanged Repair queued
Form CDC 57.115 57.115_CUS_BLANK Form Unchanged Repair queued
Form CDC 57.115 57.115_CUS_BLANK Form Unchanged Repair queued
Form CDC 57.113 57.113 Pediatric Ventilator-Associated Event (PedVAE) Form Modified Available
Form CDC 57.113 57.113 Pediatric Ventilator-Associated Event (PedVAE) Form Modified Repair queued
Form CDC 57.506 57.506 Dialysis Patient Influenza Vaccination Denominator Form Unchanged Repair queued
Form CDC 57.506 57.506 Dialysis Patient Influenza Vaccination Denominator Form Unchanged Repair queued
Form CDC 57.505 57.505 Dialysis Patient Influenza Vaccination Form Unchanged Available
Form CDC 57.505 57.505 Dialysis Patient Influenza Vaccination Form Unchanged Repair queued
Form CDC 57.504 57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form Unchanged Repair queued
Form CDC 57.504 57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form Unchanged Repair queued
Form CDC 57.501 57.501 Dialysis Monthly Reporting Plan Form Unchanged Available
Form CDC 57.501 57.501 Dialysis Monthly Reporting Plan Form Unchanged Repair queued
Form CDC 57.403 57.403 Outpatient Procedure Component - Monthly Denominators and Summary Form Unchanged Available
Form CDC 57.403 57.403 Outpatient Procedure Component - Monthly Denominators and Summary Form Unchanged Missing upstream
Form CDC 57.402 57.402 Outpatient Procedure Component Event Form Unchanged Available
Form CDC 57.402 57.402 Outpatient Procedure Component Event Form Unchanged Repair queued
Form CDC 57.401 57.401 Outpatient Procedure - Monthly Reporting Plan Form Unchanged Repair queued
Form CDC 57.401 57.401 Outpatient Procedure - Monthly Reporting Plan Form Unchanged Repair queued
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey Form Unchanged Available
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey Form Unchanged Repair queued
Form CDC 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form Modified Available
Form CDC 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form Modified Repair queued
Form 57.150 57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form and Instruction Modified Available
Form 57.150 57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form and Instruction Modified Repair queued
Form CDC 57.143 57.143 Prevention Process Measures Monthly Monitoring for LTCF Form Unchanged Available
Form CDC 57.143 57.143 Prevention Process Measures Monthly Monitoring for LTCF Form Unchanged Repair queued
Form CDC 57.142 57.142 Denominators for LTCF Locations Form Unchanged Repair queued
Form CDC 57.142 57.142 Denominators for LTCF Locations Form Unchanged Repair queued
Form CDC 57.141 57.141 Monthly Reporting Plan for LTCF Form Unchanged Available
Form CDC 57.141 57.141 Monthly Reporting Plan for LTCF Form Unchanged Repair queued
Form CDC 57.112 57.112 Ventilator-Associated Event (VAE) Form Modified Available
Form CDC 57.112 57.112 Ventilator-Associated Event (VAE) Form Modified Repair queued
Form CDC 57.139 57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Form Unchanged Available
Form CDC 57.139 57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Form Unchanged Repair queued
Form CDC 57.138 57.138 Laboratory-Identified MDRO or CDI Event for LTCF Form Unchanged Available
Form CDC 57.138 57.138 Laboratory-Identified MDRO or CDI Event for LTCF Form Unchanged Repair queued
Form CDC 57.137 57.137 Long Term care Facility Component--Annual Facility Survey Form Unchanged Available
Form CDC 57.137 57.137 Long Term care Facility Component--Annual Facility Survey Form Unchanged Repair queued
Form CDC 57.305 57.305 Hemovigilance Incident Form Unchanged Available
Form CDC 57.305 57.305 Hemovigilance Incident Form Unchanged Repair queued
Form CDC 57.303 57.303 Hemovigilance Module Monthly Reporting Denominators Form Unchanged Repair queued
Form CDC 57.303 57.303 Hemovigilance Module Monthly Reporting Denominators Form Unchanged Repair queued
Form 57.301 57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction Unchanged Available
Form 57.301 57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction Unchanged Repair queued
Form CDC 57.300 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form Unchanged Available
Form CDC 57.300 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form Unchanged Repair queued
Form CDC 57.200 57.200 Healthcare Personnel Safety Component Facility Survey Form Unchanged Available
Form CDC 57.200 57.200 Healthcare Personnel Safety Component Facility Survey Form Unchanged Repair queued
Form CDC 57.204 57.204 Healthcare Worker Demographic Data Form Unchanged Available
Form CDC 57.204 57.204 Healthcare Worker Demographic Data Form Unchanged Repair queued
Form CDC 57.206 57.206 Healthcare Worker Prophylaxis/Treatment Form Unchanged Available
Form CDC 57.206 57.206 Healthcare Worker Prophylaxis/Treatment Form Unchanged Repair queued
Form CDC 57.205 57.205 Exposure to Blood and Body Fluids Form Unchanged Available
Form CDC 57.205 57.205 Exposure to Blood and Body Fluids Form Unchanged Repair queued
Form CDC 57.105 57.105 Group Contact Information Form Unchanged Available
Form CDC 57.105 57.105 Group Contact Information Form Unchanged Repair queued
Form 57.140 57.140 Urinary Tract Infection (UTI) for LTCF Form and Instruction Modified Repair queued
Form 57.140 57.140 Urinary Tract Infection (UTI) for LTCF Form and Instruction Modified Repair queued
Form 57.103 57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction Modified Available
Form 57.103 57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction Modified Repair queued
Form CDC 57.101 57.101 Facility Contact Information Form Unchanged Available
Form CDC 57.101 57.101 Facility Contact Information Form Unchanged Repair queued
Form 57.124 57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Form and Instruction Modified Repair queued
Form 57.124 57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Form and Instruction Modified Repair queued
Form 57.123 57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Form and Instruction Modified Repair queued
Form 57.123 57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Form and Instruction Modified Repair queued
Form CDC 57.100 57.100 NHSN Registration Form Form Unchanged Available
Form CDC 57.100 57.100 NHSN Registration Form Form Unchanged Repair queued
Form CDC 57.121 57.121 Denominators for Procedure Form Modified Available
Form CDC 57.121 57.121 Denominators for Procedure Form Modified Repair queued
Form CDC 57.128 57.128 Laboratory Identified or CDI MDRO Event Form Unchanged Available
Form CDC 57.128 57.128 Laboratory Identified or CDI MDRO Event Form Unchanged Repair queued
Form CDC 57.120 57.120 Surgical Site Infection (SSI) Form Unchanged Repair queued
Form CDC 57.120 57.120 Surgical Site Infection (SSI) Form Unchanged Repair queued
Form CDC 57.126 57.126 MDRO or CDI Infection Event Form Unchanged Available
Form CDC 57.126 57.126 MDRO or CDI Infection Event Form Unchanged Repair queued
Form CDC 57.503 57.503 Denominators for Outpatient Dialysis Form Unchanged Repair queued
Form CDC 57.503 57.503 Denominators for Outpatient Dialysis Form Unchanged Repair queued
Form CDC 57.127 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form Unchanged Repair queued
Form CDC 57.127 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form Unchanged Repair queued
Form CDC 57.118 57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Form Unchanged Available
Form CDC 57.118 57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Form Unchanged Repair queued
Form CDC 57.207 57.207 Follow-up Laboratory Testing Form Unchanged Repair queued
Form CDC 57.207 57.207 Follow-up Laboratory Testing Form Unchanged Repair queued
Form CDC 57.117 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form Unchanged Repair queued
Form CDC 57.117 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form Unchanged Repair queued
Form CDC 57.125 57.125 Central Line Insertion Practices Adherence Monitoring Form Form Unchanged Repair queued
Form CDC 57.125 57.125 Central Line Insertion Practices Adherence Monitoring Form Form Unchanged Repair queued
Form CDC 57.116 57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form Unchanged Available
Form CDC 57.116 57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form Unchanged Repair queued
Form CDC 57.114 57.114 Urinary Tract Infection (UTI) Form Modified Repair queued
Form CDC 57.114 57.114 Urinary Tract Infection (UTI) Form Modified Repair queued
Form CDC 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form Unchanged Available
Form CDC 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form Unchanged Repair queued
Form CDC 57.111 57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Form Modified Repair queued
Form CDC 57.111 57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Form Modified Repair queued
Form CDC 57.502 57.502 Dialysis Event Form Unchanged Repair queued
Form CDC 57.502 57.502 Dialysis Event Form Unchanged Repair queued
Form 57.108 57.108 Primary Bloodstream Infection (BSI) Form and Instruction Modified Repair queued
Form 57.108 57.108 Primary Bloodstream Infection (BSI) Form and Instruction Modified Repair queued
Form 57.500 57.500 Outpatient Dialysis Center Practices Survey Form and Instruction Modified Repair queued
Form 57.500 57.500 Outpatient Dialysis Center Practices Survey Form and Instruction Modified Missing upstream
Form CDC 57.203 57.203 Healthcare Personnel Safety Reporting Plan Form Unchanged Repair queued
Form CDC 57.203 57.203 Healthcare Personnel Safety Reporting Plan Form Unchanged Repair queued
Att. D_0920-0666 Emergency 2022 Explanations and justifications.docx Supplementary Document Uploaded 2022-12-19 Repair queued
Att. D_0920-0666 Emergency 2022 Explanations and justifications.docx Supplementary Document Uploaded 2022-12-19 Repair queued
Emergency Request Memo NHSN 121722 DBJ signed.pdf Supplementary Document Uploaded 2022-12-19 Available
Emergency Request Memo NHSN 121722 DBJ signed.pdf Supplementary Document Uploaded 2022-12-19 Repair queued
0920-0666_SSB_Emergency.docx Supporting Statement B Uploaded 2022-12-19 Repair queued
0920-0666_SSB_Emergency.docx Supporting Statement B Uploaded 2022-12-19 Repair queued
0920-0666_SSA_emergency.docx Supporting Statement A Uploaded 2022-12-19 Available
0920-0666_SSA_emergency.docx Supporting Statement A Uploaded 2022-12-19 Repair queued
Att. D_0920-0666 Revision 2021 Explanations and justifications (002)_updated.docx Justification for No Material/Nonsubstantive Change Uploaded 2021-12-31 Available
Att. D_0920-0666 Revision 2021 Explanations and justifications (002)_updated.docx Justification for No Material/Nonsubstantive Change Uploaded 2021-12-31 Repair queued
Att. A3 Authorizing Legislation 42 USC 242m.PDF Supplementary Document Uploaded 2021-12-29 Available
Att. A3 Authorizing Legislation 42 USC 242m.PDF Supplementary Document Uploaded 2021-12-29 Repair queued
Att. A2 Authorizing Legislation 42 USC 242k.PDF Supplementary Document Uploaded 2021-12-29 Available
Att. A2 Authorizing Legislation 42 USC 242k.PDF Supplementary Document Uploaded 2021-12-29 Repair queued
Att. A1 Authorizing Legislation 42 USC 242b.PDF Supplementary Document Uploaded 2021-12-29 Available
Att. A1 Authorizing Legislation 42 USC 242b.PDF Supplementary Document Uploaded 2021-12-29 Repair queued
Change Memo for NHSN Influenza Vaccine additions_0666.docx Justification for No Material/Nonsubstantive Change Uploaded 2021-04-13 Repair queued
Change Memo for NHSN Influenza Vaccine additions_0666.docx Justification for No Material/Nonsubstantive Change Uploaded 2021-04-13 Repair queued
0920-0666 Change Memo - NHSN Facility Change request form.docx Justification for No Material/Nonsubstantive Change Uploaded 2021-02-23 Available
0920-0666 Change Memo - NHSN Facility Change request form.docx Justification for No Material/Nonsubstantive Change Uploaded 2021-02-23 Repair queued
60d FRN 15JUN2020.pdf Supplementary Document Uploaded 2020-11-25 Available
60d FRN 15JUN2020.pdf Supplementary Document Uploaded 2020-11-25 Repair queued
20200122 NHSN PIA Signed.pdf Supplementary Document Uploaded 2020-11-19 Repair queued
20200122 NHSN PIA Signed.pdf Supplementary Document Uploaded 2020-11-19 Repair queued
Change Memo for COVID HAI 060320_AW.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-06-08 Repair queued
Change Memo for COVID HAI 060320_AW.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-06-08 Repair queued
Change Memo for COVID HAI 060320.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-06-04 Available
Change Memo for COVID HAI 060320.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-06-04 Repair queued
CMS Cross walk 11.16.18.docx Supplementary Document Uploaded 2018-11-29 Available
CMS Cross walk 11.16.18.docx Supplementary Document Uploaded 2018-11-29 Repair queued
I. PIA.pdf Supplementary Document Uploaded 2018-10-09 Available
I. PIA.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
2. NHSN 308d Request for Extension and Ammendment.docx Supplementary Document Uploaded 2017-09-25 Available
2. NHSN 308d Request for Extension and Ammendment.docx Supplementary Document Uploaded 2017-09-25 Repair queued
1. NHSN 308d Approval 2015.pdf Supplementary Document Uploaded 2017-09-25 Available
1. NHSN 308d Approval 2015.pdf Supplementary Document Uploaded 2017-09-25 Missing upstream
1. NHSN 308d Approval 2015.pdf Supplementary Document Uploaded 2018-10-09 Available
1. NHSN 308d Approval 2015.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
2. NHSN - Report of End of Human Research Review 0.1253.docx Supplementary Document Uploaded 2018-10-09 Available
2. NHSN - Report of End of Human Research Review 0.1253.docx Supplementary Document Uploaded 2018-10-09 Repair queued
Closure CDC Protocol # 4062.docx Supplementary Document Uploaded 2018-10-09 Repair queued
Closure CDC Protocol # 4062.docx Supplementary Document Uploaded 2018-10-09 Repair queued
6. Inpatient Psychiatric Facilities - FLU.pdf Supplementary Document Uploaded 2018-10-09 Available
6. Inpatient Psychiatric Facilities - FLU.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
5. Ambulatory Surgery Centers & Outpatient Acute Care Facility Departments - Flu.pdf Supplementary Document Uploaded 2018-10-09 Available
5. Ambulatory Surgery Centers & Outpatient Acute Care Facility Departments - Flu.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
4. Dialysis Facilities - Dialysis Event, FLU.pdf Supplementary Document Uploaded 2018-10-09 Available
4. Dialysis Facilities - Dialysis Event, FLU.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
3. Inpatient Rehabiliation Facilities - CAUTI, MRSA LabID, CDI LabID, Flu.pdf Supplementary Document Uploaded 2018-10-09 Available
3. Inpatient Rehabiliation Facilities - CAUTI, MRSA LabID, CDI LabID, Flu.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
2. Antimicrobial Use and Resistance.pdf Supplementary Document Uploaded 2018-10-03 Available
2. Antimicrobial Use and Resistance.pdf Supplementary Document Uploaded 2018-10-03 Repair queued
1. NHSN Forms used for CMS QRPs State Mandated Reporting FINAL V3.docx Supplementary Document Uploaded 2018-10-03 Available
1. NHSN Forms used for CMS QRPs State Mandated Reporting FINAL V3.docx Supplementary Document Uploaded 2018-10-03 Repair queued
4. Revision of Estimated Annual Cost Burden.docx Supplementary Document Uploaded 2019-10-10 Repair queued
4. Revision of Estimated Annual Cost Burden.docx Supplementary Document Uploaded 2019-10-10 Missing upstream
3. Revision of Estimated Annual Burden Hours.docx Supplementary Document Uploaded 2019-10-10 Repair queued
3. Revision of Estimated Annual Burden Hours.docx Supplementary Document Uploaded 2019-10-10 Repair queued
2. Itemized IC Revisions and Justifications LW clean.docx Supplementary Document Uploaded 2019-12-02 Repair queued
2. Itemized IC Revisions and Justifications LW clean.docx Supplementary Document Uploaded 2019-12-02 Repair queued
1. Explanations and justifications.docx Supplementary Document Uploaded 2019-10-10 Available
1. Explanations and justifications.docx Supplementary Document Uploaded 2019-10-10 Repair queued
Published 60dy FRN.pdf Supplementary Document Uploaded 2019-10-10 Available
Published 60dy FRN.pdf Supplementary Document Uploaded 2019-10-10 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
7134 57.106 Patient Safety Monthly Reporting Plan Form and Instruction Modified
7134 57.106 Patient Safety Monthly Reporting Plan Form and Instruction Modified
257463 Monthly Survey Patient Days & Nurse Staffing Form and Instruction New
257463 Monthly Survey Patient Days & Nurse Staffing Form and Instruction New
246758 Annual Healthcare Personnel Influenza Vaccination Summary Form and Instruction Unchanged
246758 Annual Healthcare Personnel Influenza Vaccination Summary Form and Instruction Unchanged
246757 Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Unchanged
246757 Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Unchanged
246756 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Unchanged
246756 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Unchanged
246755 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities Form and Instruction Unchanged
246755 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities Form and Instruction Unchanged
244476 57.135 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) Form and Instruction Unchanged
244476 57.135 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) Form and Instruction Unchanged
238093 57.136 Long Term Care Facility Component - Respiratory Tract Infection Form and Instruction Unchanged
238093 57.136 Long Term Care Facility Component - Respiratory Tract Infection Form and Instruction Unchanged
237430 57.104 NHSN Administrator Change Request Form Form and Instruction Unchanged
237430 57.104 NHSN Administrator Change Request Form Form and Instruction Unchanged
233214 57.122 HAI Progress Report State Health Department Survey Form Unchanged
233214 57.122 HAI Progress Report State Health Department Survey Form Unchanged
228154 57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Form Unchanged
228154 57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Form Unchanged
228153 57.404 Outpatient Procedure Component - SSI Denominators Form Unchanged
228153 57.404 Outpatient Procedure Component - SSI Denominators Form Unchanged
222908 57.507_HomeDialysisSurv Form Unchanged
222908 57.507_HomeDialysisSurv Form Unchanged
222907 57.320_HV AR-Other_BLANK Form Unchanged
222907 57.320_HV AR-Other_BLANK Form Unchanged
222906 57.319_HV AR-UNK_BLANK Form Unchanged
222906 57.319_HV AR-UNK_BLANK Form Unchanged
222905 57.318_HV AR-TACO_BLANK Form Unchanged
222905 57.318_HV AR-TACO_BLANK Form Unchanged
222904 57.317_HV AR-TRALI_BLAN Form Unchanged
222904 57.317_HV AR-TRALI_BLAN Form Unchanged
222903 57.316_HV AR-TAGVHD_BLAN Form Unchanged
222903 57.316_HV AR-TAGVHD_BLAN Form Unchanged
222902 57.315_HV AR-TAD_BLAN Form Unchanged
222902 57.315_HV AR-TAD_BLAN Form Unchanged
222901 57.314_HV AR-PTP_BLAN Form Unchanged
222901 57.314_HV AR-PTP_BLAN Form Unchanged
222900 57.313_HV AR-Infection_BLAN Form Unchanged
222900 57.313_HV AR-Infection_BLAN Form Unchanged
222899 57.312_HV AR-HTR_BLANK Form Unchanged
222899 57.312_HV AR-HTR_BLANK Form Unchanged
222898 57.311_HV AR-FNHTR_BLANK Form Unchanged
222898 57.311_HV AR-FNHTR_BLANK Form Unchanged
222897 57.310_HV AR-DSTR_BLANK Form Unchanged
222897 57.310_HV AR-DSTR_BLANK Form Unchanged
222896 57.309_HV AR-DHTR_BLANK Form Unchanged
222896 57.309_HV AR-DHTR_BLANK Form Unchanged
222895 57.308_HV AR-Allergic_BLANK Form Unchanged
222895 57.308_HV AR-Allergic_BLANK Form Unchanged
222894 57.307_HV AR-AHTR_BLANK Form Unchanged
222894 57.307_HV AR-AHTR_BLANK Form Unchanged
222893 57.306_HV Annual Facility Sur Form Unchanged
222893 57.306_HV Annual Facility Sur Form Unchanged
222892 57.129_Adult Sepsis_BLANK Form Unchanged
222892 57.129_Adult Sepsis_BLANK Form Unchanged
222891 57.115_CUS_BLANK Form Unchanged
222891 57.115_CUS_BLANK Form Unchanged
222890 57.113 Pediatric Ventilator-Associated Event (PedVAE) Form Modified
222890 57.113 Pediatric Ventilator-Associated Event (PedVAE) Form Modified
208411 57.506 Dialysis Patient Influenza Vaccination Denominator Form Unchanged
208411 57.506 Dialysis Patient Influenza Vaccination Denominator Form Unchanged
208410 57.505 Dialysis Patient Influenza Vaccination Form Unchanged
208410 57.505 Dialysis Patient Influenza Vaccination Form Unchanged
208409 57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form Unchanged
208409 57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form Unchanged
208408 57.501 Dialysis Monthly Reporting Plan Form Unchanged
208408 57.501 Dialysis Monthly Reporting Plan Form Unchanged
208407 57.403 Outpatient Procedure Component - Monthly Denominators and Summary Form Unchanged
208407 57.403 Outpatient Procedure Component - Monthly Denominators and Summary Form Unchanged
208406 57.402 Outpatient Procedure Component Event Form Unchanged
208406 57.402 Outpatient Procedure Component Event Form Unchanged
208405 57.401 Outpatient Procedure - Monthly Reporting Plan Form Unchanged
208405 57.401 Outpatient Procedure - Monthly Reporting Plan Form Unchanged
208404 57.400 Outpatient Procedure - Annual Facility Survey Form Unchanged
208404 57.400 Outpatient Procedure - Annual Facility Survey Form Unchanged
200382 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form Modified
200382 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form Modified
200381 57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form and Instruction Modified
200381 57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form and Instruction Modified
200380 57.143 Prevention Process Measures Monthly Monitoring for LTCF Form Unchanged
200380 57.143 Prevention Process Measures Monthly Monitoring for LTCF Form Unchanged
200379 57.142 Denominators for LTCF Locations Form Unchanged
200379 57.142 Denominators for LTCF Locations Form Unchanged
200378 57.141 Monthly Reporting Plan for LTCF Form Unchanged
200378 57.141 Monthly Reporting Plan for LTCF Form Unchanged
200377 57.112 Ventilator-Associated Event (VAE) Form Modified
200377 57.112 Ventilator-Associated Event (VAE) Form Modified
197543 57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Form Unchanged
197543 57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Form Unchanged
197542 57.138 Laboratory-Identified MDRO or CDI Event for LTCF Form Unchanged
197542 57.138 Laboratory-Identified MDRO or CDI Event for LTCF Form Unchanged
197541 57.137 Long Term care Facility Component--Annual Facility Survey Form Unchanged
197541 57.137 Long Term care Facility Component--Annual Facility Survey Form Unchanged
190364 57.305 Hemovigilance Incident Form Unchanged
190364 57.305 Hemovigilance Incident Form Unchanged
190363 57.303 Hemovigilance Module Monthly Reporting Denominators Form Unchanged
190363 57.303 Hemovigilance Module Monthly Reporting Denominators Form Unchanged
190361 57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction Unchanged
190361 57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction Unchanged
190360 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form Unchanged
190360 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form Unchanged
183582 57.200 Healthcare Personnel Safety Component Facility Survey Form Unchanged
183582 57.200 Healthcare Personnel Safety Component Facility Survey Form Unchanged
183579 57.204 Healthcare Worker Demographic Data Form Unchanged
183579 57.204 Healthcare Worker Demographic Data Form Unchanged
183578 57.206 Healthcare Worker Prophylaxis/Treatment Form Unchanged
183578 57.206 Healthcare Worker Prophylaxis/Treatment Form Unchanged
183577 57.205 Exposure to Blood and Body Fluids Form Unchanged
183577 57.205 Exposure to Blood and Body Fluids Form Unchanged
183576 57.105 Group Contact Information Form Unchanged
183576 57.105 Group Contact Information Form Unchanged
183573 57.140 Urinary Tract Infection (UTI) for LTCF Form and Instruction Modified
183573 57.140 Urinary Tract Infection (UTI) for LTCF Form and Instruction Modified
183572 57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction Modified
183572 57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction Modified
183570 57.101 Facility Contact Information Form Unchanged
183570 57.101 Facility Contact Information Form Unchanged
183568 57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Form and Instruction Modified
183568 57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Form and Instruction Modified
183566 57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Form and Instruction Modified
183566 57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Form and Instruction Modified
183565 57.100 NHSN Registration Form Form Unchanged
183565 57.100 NHSN Registration Form Form Unchanged
183564 57.121 Denominators for Procedure Form Modified
183564 57.121 Denominators for Procedure Form Modified
183563 57.128 Laboratory Identified or CDI MDRO Event Form Unchanged
183563 57.128 Laboratory Identified or CDI MDRO Event Form Unchanged
183562 57.120 Surgical Site Infection (SSI) Form Unchanged
183562 57.120 Surgical Site Infection (SSI) Form Unchanged
183561 57.126 MDRO or CDI Infection Event Form Unchanged
183561 57.126 MDRO or CDI Infection Event Form Unchanged
183560 57.503 Denominators for Outpatient Dialysis Form Unchanged
183560 57.503 Denominators for Outpatient Dialysis Form Unchanged
183559 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form Unchanged
183559 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form Unchanged
183558 57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Form Unchanged
183558 57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Form Unchanged
183557 57.207 Follow-up Laboratory Testing Form Unchanged
183557 57.207 Follow-up Laboratory Testing Form Unchanged
183556 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form Unchanged
183556 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form Unchanged
183555 57.125 Central Line Insertion Practices Adherence Monitoring Form Form Unchanged
183555 57.125 Central Line Insertion Practices Adherence Monitoring Form Form Unchanged
183554 57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form Unchanged
183554 57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form Unchanged
183551 57.114 Urinary Tract Infection (UTI) Form Modified
183551 57.114 Urinary Tract Infection (UTI) Form Modified
183550 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form Unchanged
183550 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form Unchanged
183549 57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Form Modified
183549 57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Form Modified
183547 57.502 Dialysis Event Form Unchanged
183547 57.502 Dialysis Event Form Unchanged
183545 57.108 Primary Bloodstream Infection (BSI) Form and Instruction Modified
183545 57.108 Primary Bloodstream Infection (BSI) Form and Instruction Modified
183544 57.500 Outpatient Dialysis Center Practices Survey Form and Instruction Modified
183544 57.500 Outpatient Dialysis Center Practices Survey Form and Instruction Modified
183543 57.203 Healthcare Personnel Safety Reporting Plan Form Unchanged
183543 57.203 Healthcare Personnel Safety Reporting Plan Form Unchanged
ICR Details
StatusActive
Agency/SubagencyHHS/CDC
OMB Control No0920-0666
Type of Information CollectionRevision of a currently approved collection
Previous ICR Reference No202112-0920-014
Agency Tracking No0920-0666
Date Submitted to OIRA2022-12-21
Requested Expiration Date2022-12-30