[NCEZID] The National Healthcare Safety Network (NHSN)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 57.106 Patient Safety Monthly Reporting Plan	Form and Instruction	Modified	Available
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	Modified	Available
Monthly Survey Patient Days & Nurse Staffing	Form and Instruction	Modified	Available
Monthly Survey Patient Days & Nurse Staffing	Form and Instruction	Modified	Repair queued
Form 0920-0666 Annual Healthcare Personnel Influenza Vaccination Summary	Form and Instruction	Unchanged	Repair queued
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	Available
Form 0920-0666 Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Unchanged	Repair queued
Form 0920-0666 Weekly HCP Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Unchanged	Available
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 HCP Influenza Vaccination Cumulative Summary Non-Long-Term Care Facilities	Form and Instruction	Unchanged	Available
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 for monthly electronic upload	Form and Instruction	Unchanged	Available
Form 57.135 57.135 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly)	Form and Instruction	Unchanged	Repair queued
Form 57.136 Long-Term Care Facility Component – Respiratory Tract Infection	Form and Instruction	Unchanged	Available
Form 57.136 57.136 Long Term Care Facility Component - Respiratory Tract Infection	Form and Instruction	Unchanged	Repair queued
Facility Administrator Change Request	Form and Instruction	Unchanged	Available
57.104 NHSN Administrator Change Request Form	Form and Instruction	Unchanged	Repair queued
Form CDC 55.122 State Health Department HAI Mandate and Validatyion Survey	Form	Unchanged	Available
Form CDC 55.122 57.122 HAI Progress Report State Health Department Survey	Form	Unchanged	Repair queued
Form CDC 57.405 Outpatient Procedure Component - SSI Denominators	Form	Modified	Available
Form CDC 57.405 57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event	Form	Modified	Repair queued
Form 57.404 Outpatient Procedure Component - SSI Denominators	Form	Modified	Available
Form 57.404 57.404 Outpatient Procedure Component - SSI Denominators	Form	Modified	Repair queued
Form 57.507 57.507_dialhomesurv_2020_final	Form and Instruction	Modified	Available
Form 57.507 57.507 Home Dialysis Center Practices Survey	Form	Modified	Available
Form 57.507 57.507 Home Dialysis Center Practices Survey	Form	Modified	Repair queued
Form CDC 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction (with revised GISAB questions)	Form	Modified	Available
Form 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	Form	Modified	Available
Form 57.320 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction (with modified GISAB questions)	Form	Modified	Available
Form CDC 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.319 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload (with revised GISAB questions)	Form	Modified	Available
Form 57.318 Hemoviligance Adverse Reaction - Transfusion Associated Circulatory Overload	Form	Modified	Available
Form 57.318 57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	Form	Modified	Repair queued
Form CDC 57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury (with revised GISAB questions)	Form	Modified	Available
Form 57.317 Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury	Form	Modified	Repair queued
Form 57.317 57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury	Form	Modified	Repair queued
Form CDC 57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease (with revised GISAB questions)	Form	Modified	Available
Form CDC 57.316 Hemovigilance Adverse Reaction - Transfusin Associated Graft vs. Host Disease	Form	Modified	Available
Form CDC 57.316 57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease	Form	Modified	Repair queued
Form CDC 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea (with revised GISAB questions)	Form	Modified	Available
Form CDC 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	Form	Modified	Available
Form CDC 57.315 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	Form	Modified	Repair queued
Form CDC 57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura (with revised GISAB questions)	Form	Modified	Available
Form 57.314 Hwemovilgilance Adverse Reaction - Post Transfusion Purpura	Form	Modified	Available
Form 57.314 57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura	Form	Modified	Repair queued
Form CDC 57.313 Hemovigilance Adverse Reaction - Infection (with revised GISAB questions)	Form	Modified	Available
Form 57.313 Hemovigilance Adverse Reaction - Infection	Form	Modified	Available
Form 57.313 57.313 Hemovigilance Adverse Reaction - Infection	Form	Modified	Repair queued
Form CDC 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction (with modified GISAB questions)	Form	Modified	Available
Form 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	Form	Modified	Available
Form 57.312 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.311 57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction (with revised GISAB questions)	Form	Modified	Available
Form CDC 57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.311 57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction (with revised GISAB questions)	Form	Modified	Available
Form 57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	Form	Modified	Available
Form 57.310 57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction (with revised GISAB questions)	Form	Modified	Available
Form CDC 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.309 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.308 Hemovigilance Module Adverse Reaction Allergic Transfusion Reaction (with revised GISAB questions)	Form	Modified	Available
Form 57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	Form	Modified	Available
Form 57.308 57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction (with revised GISAB questions)	Form	Modified	Available
Form 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	Form	Modified	Available
Form 57.307 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facilities (with revised GISAB questions)	Form	Modified	Available
Form 57.306 Hemovigilance Module Annual Survey - Non-acute Care Facility	Form	Modified	Available
Form 57.306 57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility	Form	Modified	Repair queued
Form 57.129 Adult Sepsis_	Form	Modified	Available
Form 57.129 57.129_Adult Sepsis_BLANK	Form	Modified	Repair queued
Form CDC 57.115 Custom Event	Form	Modified	Available
Form CDC 57.115 57.115 Custom Event	Form	Modified	Repair queued
Form 57.113 Pediatric Ventilator-Associated Event (PedVAE)	Form and Instruction	Modified	Available
Form 57.113 57.113 Pediatric Ventilator-Associated Event (PedVAE)	Form and Instruction	Modified	Repair queued
Form CDC 57.506 Dialysis Patient Influenza Vaccination Denominator	Form	Modified	Available
Form CDC 57.506 57.506 Dialysis Patient Influenza Vaccination Denominator	Form	Modified	Repair queued
Form CDC 57.505 Dialysis Patient Influenza Vaccination	Form	Modified	Available
Form CDC 57.505 57.505 Dialysis Patient Influenza Vaccination	Form	Modified	Repair queued
Form CDC 57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Modified	Repair queued
Form CDC 57.504 57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Modified	Repair queued
Form CDC 57.501 NHSN Registration Form	Form	Modified	Available
Form CDC 57.501 57.501 Dialysis Monthly Reporting Plan	Form	Modified	Repair queued
Form CDC 57.403 Outpatient Procedure - Monthly Denominators and Summary	Form	Modified	Available
Form CDC 57.403 57.403 Outpatient Procedure Component - Monthly Denominators and Summary	Form	Modified	Repair queued
Form CDC 57.402 Outpatient Procedure - Component Event	Form	Modified	Available
Form CDC 57.402 57.402 Outpatient Procedure Component Event	Form	Modified	Repair queued
Form CDC 57.401 Outpatient Procedure Component - Monthly Reporting Plan	Form	Modified	Available
Form CDC 57.401 57.401 Outpatient Procedure - Monthly Reporting Plan	Form	Modified	Repair queued
Form CDC 57.400 Outpatient Procedure Component - Annual Facility Survey	Form	Modified	Available
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey	Form	Modified	Repair queued
Form 57.151 Patient Safety Component—Annual Facility Survey for IRF	Form and Instruction	Modified	Available
Form 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF	Form and Instruction	Modified	Repair queued
Form 57.150 Urinary Tract Infection (UTI) for LTCF	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 Prevention Process Measures Monthly Monitoring	Form	Modified	Available
Form CDC 57.143 57.143 Prevention Process Measures Monthly Monitoring for LTCF	Form	Modified	Repair queued
Form CDC 57.142 Denominators for LTCF	Form	Modified	Available
Form CDC 57.142 57.142 Denominators for LTCF Locations	Form	Modified	Repair queued
Form CDC 57.141 Monthly Reporting Plan for LTCF	Form	Modified	Available
Form CDC 57.141 57.141 Monthly Reporting Plan for LTCF	Form	Modified	Repair queued
Form 57.112 Ventilator Associated Event (VAE)	Form and Instruction	Modified	Available
Form 57.112 57.112 Ventilator-Associated Event (VAE)	Form and Instruction	Modified	Repair queued
Form CDC 57.139 MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF	Form	Modified	Available
Form CDC 57.139 57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF	Form	Modified	Repair queued
Form CDC 57.138 Laboratory-identified MDRO or CDI Event for LTCF	Form	Modified	Repair queued
Form CDC 57.138 57.138 Laboratory-Identified MDRO or CDI Event for LTCF	Form	Modified	Repair queued
Form CDC 57.137 Long-Term Care Facility Component -- Annual Facility Survey	Form	Modified	Available
Form CDC 57.137 57.137 Long Term care Facility Component--Annual Facility Survey	Form	Modified	Repair queued
Form CDC 57.305 Hemovigilance Module Incident	Form	Modified	Available
Form CDC 57.305 57.305 Hemovigilance Incident	Form	Modified	Repair queued
Form CDC 57.303 Hemovigilance Module Monthly Reporting Denominators	Form and Instruction	Modified	Available
Form CDC 57.303 57.303 Hemovigilance Module Monthly Reporting Denominators	Form	Modified	Repair queued
Form 57.301 57.301_HV Monthly Reporting Plan_BLANK	Form and Instruction	Modified	Available
Form 57.301 57.301 Hemovigilance Module Monthly Reporting Plan	Form and Instruction	Modified	Repair queued
Form 57.300 Hemovigilance Module Annual Survey (with revised GISAB questions)	Form	Modified	Available
Form CDC 57.300 Hemovigilance Module - Annual Survey	Form	Modified	Available
Form CDC 57.300 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility	Form	Modified	Repair queued
Form CDC 57.200 Healthcare Personnel Safety - Annual Facility Survey	Form	Modified	Available
Form CDC 57.200 57.200 Healthcare Personnel Safety Component Facility Survey	Form	Modified	Repair queued
Form CDC 57.204 Healthcare Worker Demographic Data	Form	Modified	Available
Form CDC 57.204 57.204 Healthcare Worker Demographic Data	Form	Modified	Repair queued
Form CDC 57.206 Healthcare Worker Prophylaxis/Treatment	Form	Modified	Available
Form CDC 57.206 57.206 Healthcare Worker Prophylaxis/Treatment	Form	Modified	Repair queued
Form CDC 57.205 Exposure to Blood/Body Fluids	Form	Modified	Available
Form CDC 57.205 57.205 Exposure to Blood and Body Fluids	Form	Modified	Repair queued
Form CDC 57.105 Group Contact Information	Form	Modified	Available
Form CDC 57.105 57.105 Group Contact Information	Form	Modified	Repair queued
Form 57.140 Urinary Tract Infection (UTI) for LTCF	Form and Instruction	Modified	Available
Form 57.140 57.140_LTCF UTI_Form_2022	Form and Instruction	Modified	Available
Form 57.140 57.140 Urinary Tract Infection (UTI) for LTCF	Form and Instruction	Modified	Repair queued
Patient Safety Component-Annual Hospital Survey (changes for 2023)	Form and Instruction	Modified	Available
57.103 Patient Safety Component - Annual Hospital Survey	Form and Instruction	Modified	Repair queued
Form CDC 57.101 Facility Contact Information	Form	Modified	Available
Form CDC 57.101 57.101 Facility Contact Information	Form	Modified	Repair queued
Form 57.124 Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables	Form and Instruction	Modified	Available
Form 57.124 57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	Form and Instruction	Modified	Repair queued
Form 57.123 Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables	Form and Instruction	Modified	Available
Form 57.123 57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables	Form and Instruction	Modified	Repair queued
Form CDC 57.100 NHSN Registration Form	Form	Modified	Available
Form CDC 57.100 57.100 NHSN Registration Form	Form	Modified	Repair queued
Form 57.121 Denominator for Procedure	Form and Instruction	Modified	Available
Form 57.121 57.121 Denominators for Procedure	Form and Instruction	Modified	Repair queued
Form 57.128 Laboratory-identified MDRO or CDI Event (with revised GISAB questions)	Form	Modified	Available
Form CDC 57.128 Rev 7, Lab ID Event	Form and Instruction	Modified	Available
Form CDC 57.128 Rev 7, 57.128 Laboratory Identified or CDI MDRO Event	Form and Instruction	Modified	Repair queued
Form CDC 57.120 Surgical Site Infection	Form	Modified	Available
Form CDC 57.120 57.120 Surgical Site Infection (SSI)	Form	Modified	Available
Form 57.126 MDRO or CDI Infection Event (with revised GISAB questions)	Form	Modified	Available
Form CDC 57.126 MDRO or CDI Infection Event	Form	Modified	Available
Form CDC 57.126 57.126 MDRO or CDI Infection Event	Form	Modified	Repair queued
Form CDC 57.503 Demominators for Dialysis Event Surveillance	Form	Modified	Available
Form CDC 57.503 57.503 Denominators for Outpatient Dialysis	Form	Modified	Repair queued
Form CDC 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting	Form	Modified	Available
Form CDC 57.127 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	Form	Modified	Repair queued
Form CDC 57.118 Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)	Form	Modified	Available
Form CDC 57.118 57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)	Form	Modified	Repair queued
Form CDC 57.207 Follow-up Laboratory Testing	Form	Modified	Available
Form CDC 57.207 57.207 Follow-up Laboratory Testing	Form	Modified	Repair queued
Form CDC 57.117 Denominators for Specialty Care Area (SCA)/Oncology (ONC)	Form	Modified	Available
Form CDC 57.117 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)	Form	Modified	Repair queued
Form CDC 57.115 Central Line Insertion Practices Adherence Monitoring (revised GISAB questions)	Form	Modified	Available
Form CDC 57.125 Central Line Insertion Practices Adherence Monitoring	Form	Modified	Available
Form CDC 57.125 57.125 Central Line Insertion Practices Adherence Monitoring Form	Form	Modified	Repair queued
Form CDC 57.116 PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)	Form	Modified	Available
Form CDC 57.116 57.116 Denominators for Neonatal Intensive Care Unit (NICU)	Form	Modified	Repair queued
Form 57.114 Urinary Tract infection (UTI)	Form and Instruction	Modified	Available
Form 57.114 57.114 Urinary Tract Infection (UTI)	Form and Instruction	Modified	Repair queued
Form CDC 57.210 HCW Prophylaxis/Treatment-Influenza	Form	Modified	Repair queued
Form CDC 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Form	Modified	Repair queued
Form 57.111 Pneumonia (PNEU)	Form and Instruction	Modified	Available
Form 57.111 57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	Form and Instruction	Modified	Repair queued
Form CDC 57.502 Dialysis Event	Form and Instruction	Modified	Available
Form CDC 57.502 57.502 Dialysis Event	Form and Instruction	Modified	Repair queued
Form 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 Home Dialysis Center Practices Survey	Form and Instruction	Modified	Available
Form 57.500 57.500 Outpatient Dialysis Center Practices Survey	Form and Instruction	Modified	Repair queued
Form CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan	Form	Modified	Available
Form CDC 57.203 57.203 Healthcare Personnel Safety Reporting Plan	Form	Modified	Repair queued
I. NHSN Change Tracker_04252023.docx	Supplementary Document	Uploaded 2023-04-25	Repair queued
H2. Privacy Act Checklist 2022.docx	Supplementary Document	Uploaded 2023-01-10	Repair queued
H1. NHSN Signed PIA.pdf	Supplementary Document	Uploaded 2023-01-10	Repair queued
G2. NHSN 308d Request for Extension and Ammendment.docx	Supplementary Document	Uploaded 2023-01-10	Repair queued
G1. NHSN 308d Approval 2015.pdf	Supplementary Document	Uploaded 2023-01-10	Repair queued
F2. Report of End of Human Research Review 0.1253.docx	Supplementary Document	Uploaded 2023-01-10	Repair queued
F1. Closure CDC Protocol # 4062.docx	Supplementary Document	Uploaded 2023-01-10	Repair queued
E. NHSN Forms used for CMS QRPs State Mandated Reporting.docx	Supplementary Document	Uploaded 2023-01-10	Repair queued
D2. Itemized IC Revisions and Justifications.docx	Supplementary Document	Uploaded 2023-01-10	Repair queued
D1. 0920-0666 Revision 2022 Explanations and justifications.docx	Supplementary Document	Uploaded 2023-01-10	Repair queued
B1. public comment.pdf	Supplementary Document	Uploaded 2023-01-10	Repair queued
B. Published 60-day FRN NHSN 2022.pdf	Supplementary Document	Uploaded 2023-01-10	Repair queued
A3. 42 USC 242m.pdf	Supplementary Document	Uploaded 2023-01-10	Repair queued
A2. 42 USC 242k.pdf	Supplementary Document	Uploaded 2023-01-10	Repair queued
A1. 42 USC 242b.pdf	Supplementary Document	Uploaded 2023-01-10	Repair queued
SSB_04112023.docx	Supporting Statement B	Uploaded 2023-04-25	Repair queued
SSA_04112023.docx	Supporting Statement A	Uploaded 2023-04-25	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7134	57.106 Patient Safety Monthly Reporting Plan	Form and Instruction	Modified	Patient Safety Monthly Reporting Plan
7134	57.106 Patient Safety Monthly Reporting Plan	Form and Instruction	Modified
257463	Monthly Survey Patient Days & Nurse Staffing	Form and Instruction	Modified	Monthly Survey Patient Days & Nurse Staffing
257463	Monthly Survey Patient Days & Nurse Staffing	Form and Instruction	Modified	Monthly Survey Patient Days & Nurse Staffing
257463	Monthly Survey Patient Days & Nurse Staffing	Form and Instruction	Modified
246758	Annual Healthcare Personnel Influenza Vaccination Summary	Form and Instruction	Unchanged	Annual Healthcare Personnel Influenza Vaccination Summary
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	Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities
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	Weekly HCP Influenza Vaccination Cumulative Summary for Long-Term Care Facilities
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	Weekly HCP Influenza Vaccination Cumulative Summary Non-Long-Term Care Facilities
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	57.135 Late Onset Sepsis/ Meningitis Denominator Form: Data Table for monthly electronic upload
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	Long-Term Care Facility Component – Respiratory Tract Infection
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	Facility Administrator Change Request
237430	57.104 NHSN Administrator Change Request Form	Form and Instruction	Unchanged
233214	57.122 HAI Progress Report State Health Department Survey	Form	Unchanged	State Health Department HAI Mandate and Validatyion Survey
233214	57.122 HAI Progress Report State Health Department Survey	Form	Unchanged
228154	57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event	Form	Modified	Outpatient Procedure Component - SSI Denominators
228154	57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event	Form	Modified
228153	57.404 Outpatient Procedure Component - SSI Denominators	Form	Modified	Outpatient Procedure Component - SSI Denominators
228153	57.404 Outpatient Procedure Component - SSI Denominators	Form	Modified
222908	57.507 Home Dialysis Center Practices Survey	Form and Instruction	Modified	57.507_dialhomesurv_2020_final
222908	57.507 Home Dialysis Center Practices Survey	Form	Modified	57.507 Home Dialysis Center Practices Survey
222908	57.507 Home Dialysis Center Practices Survey	Form	Modified
222907	57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Other Transfusion Reaction (with revised GISAB questions)
222907	57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Other Transfusion Reaction
222907	57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	Form	Modified
222906	57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Unknown Transfusion Reaction (with modified GISAB questions)
222906	57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Unknown Transfusion Reaction
222906	57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	Form	Modified
222905	57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	Form	Modified	Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload (with revised GISAB questions)
222905	57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	Form	Modified	Hemoviligance Adverse Reaction - Transfusion Associated Circulatory Overload
222905	57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	Form	Modified
222904	57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury	Form	Modified	Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury (with revised GISAB questions)
222904	57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury	Form	Modified	Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury
222904	57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury	Form	Modified
222903	57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease	Form	Modified	Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease (with revised GISAB questions)
222903	57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease	Form	Modified	Hemovigilance Adverse Reaction - Transfusin Associated Graft vs. Host Disease
222903	57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease	Form	Modified
222902	57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	Form	Modified	Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea (with revised GISAB questions)
222902	57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	Form	Modified	Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea
222902	57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	Form	Modified
222901	57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura	Form	Modified	Hemovigilance Adverse Reaction - Post Transfusion Purpura (with revised GISAB questions)
222901	57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura	Form	Modified	Hwemovilgilance Adverse Reaction - Post Transfusion Purpura
222901	57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura	Form	Modified
222900	57.313 Hemovigilance Adverse Reaction - Infection	Form	Modified	Hemovigilance Adverse Reaction - Infection (with revised GISAB questions)
222900	57.313 Hemovigilance Adverse Reaction - Infection	Form	Modified	Hemovigilance Adverse Reaction - Infection
222900	57.313 Hemovigilance Adverse Reaction - Infection	Form	Modified
222899	57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction (with modified GISAB questions)
222899	57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction
222899	57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	Form	Modified
222898	57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	Form	Modified	57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction (with revised GISAB questions)
222898	57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction
222898	57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	Form	Modified
222897	57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction (with revised GISAB questions)
222897	57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction
222897	57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	Form	Modified
222896	57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction (with revised GISAB questions)
222896	57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction
222896	57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Form	Modified
222895	57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	Form	Modified	Hemovigilance Module Adverse Reaction Allergic Transfusion Reaction (with revised GISAB questions)
222895	57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Allergic Transfusion Reaction
222895	57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	Form	Modified
222894	57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction (with revised GISAB questions)
222894	57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction
222894	57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	Form	Modified
222893	57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility	Form	Modified	Hemovigilance Module Annual Facility Survey - Non-acute Care Facilities (with revised GISAB questions)
222893	57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility	Form	Modified	Hemovigilance Module Annual Survey - Non-acute Care Facility
222893	57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility	Form	Modified
222892	57.129_Adult Sepsis_BLANK	Form	Modified	Adult Sepsis_
222892	57.129_Adult Sepsis_BLANK	Form	Modified
222891	57.115 Custom Event	Form	Modified	Custom Event
222891	57.115 Custom Event	Form	Modified
222890	57.113 Pediatric Ventilator-Associated Event (PedVAE)	Form and Instruction	Modified	Pediatric Ventilator-Associated Event (PedVAE)
222890	57.113 Pediatric Ventilator-Associated Event (PedVAE)	Form and Instruction	Modified
208411	57.506 Dialysis Patient Influenza Vaccination Denominator	Form	Modified	Dialysis Patient Influenza Vaccination Denominator
208411	57.506 Dialysis Patient Influenza Vaccination Denominator	Form	Modified
208410	57.505 Dialysis Patient Influenza Vaccination	Form	Modified	Dialysis Patient Influenza Vaccination
208410	57.505 Dialysis Patient Influenza Vaccination	Form	Modified
208409	57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Modified	Prevention Process Measures Monthly Monitoring for Dialysis
208409	57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Modified
208408	57.501 Dialysis Monthly Reporting Plan	Form	Modified	NHSN Registration Form
208408	57.501 Dialysis Monthly Reporting Plan	Form	Modified
208407	57.403 Outpatient Procedure Component - Monthly Denominators and Summary	Form	Modified	Outpatient Procedure - Monthly Denominators and Summary
208407	57.403 Outpatient Procedure Component - Monthly Denominators and Summary	Form	Modified
208406	57.402 Outpatient Procedure Component Event	Form	Modified	Outpatient Procedure - Component Event
208406	57.402 Outpatient Procedure Component Event	Form	Modified
208405	57.401 Outpatient Procedure - Monthly Reporting Plan	Form	Modified	Outpatient Procedure Component - Monthly Reporting Plan
208405	57.401 Outpatient Procedure - Monthly Reporting Plan	Form	Modified
208404	57.400 Outpatient Procedure - Annual Facility Survey	Form	Modified	Outpatient Procedure Component - Annual Facility Survey
208404	57.400 Outpatient Procedure - Annual Facility Survey	Form	Modified
200382	57.151 Patient Safety Component -- Annual Facility Survey for IRF	Form and Instruction	Modified	Patient Safety Component—Annual Facility Survey for IRF
200382	57.151 Patient Safety Component -- Annual Facility Survey for IRF	Form and Instruction	Modified
200381	57.150 Patient Safety Component -- Annual Facility Survey for LTAC	Form and Instruction	Modified	Urinary Tract Infection (UTI) for LTCF
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	Modified	Prevention Process Measures Monthly Monitoring
200380	57.143 Prevention Process Measures Monthly Monitoring for LTCF	Form	Modified
200379	57.142 Denominators for LTCF Locations	Form	Modified	Denominators for LTCF
200379	57.142 Denominators for LTCF Locations	Form	Modified
200378	57.141 Monthly Reporting Plan for LTCF	Form	Modified	Monthly Reporting Plan for LTCF
200378	57.141 Monthly Reporting Plan for LTCF	Form	Modified
200377	57.112 Ventilator-Associated Event (VAE)	Form and Instruction	Modified	Ventilator Associated Event (VAE)
200377	57.112 Ventilator-Associated Event (VAE)	Form and Instruction	Modified
197543	57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF	Form	Modified	MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF
197543	57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF	Form	Modified
197542	57.138 Laboratory-Identified MDRO or CDI Event for LTCF	Form	Modified	Laboratory-identified MDRO or CDI Event for LTCF
197542	57.138 Laboratory-Identified MDRO or CDI Event for LTCF	Form	Modified
197541	57.137 Long Term care Facility Component--Annual Facility Survey	Form	Modified	Long-Term Care Facility Component -- Annual Facility Survey
197541	57.137 Long Term care Facility Component--Annual Facility Survey	Form	Modified
190364	57.305 Hemovigilance Incident	Form	Modified	Hemovigilance Module Incident
190364	57.305 Hemovigilance Incident	Form	Modified
190363	57.303 Hemovigilance Module Monthly Reporting Denominators	Form and Instruction	Modified	Hemovigilance Module Monthly Reporting Denominators
190363	57.303 Hemovigilance Module Monthly Reporting Denominators	Form	Modified
190361	57.301 Hemovigilance Module Monthly Reporting Plan	Form and Instruction	Modified	57.301_HV Monthly Reporting Plan_BLANK
190361	57.301 Hemovigilance Module Monthly Reporting Plan	Form and Instruction	Modified
190360	57.300 Hemovigilance Module Annual Survey -- Acute Care Facility	Form	Modified	Hemovigilance Module Annual Survey (with revised GISAB questions)
190360	57.300 Hemovigilance Module Annual Survey -- Acute Care Facility	Form	Modified	Hemovigilance Module - Annual Survey
190360	57.300 Hemovigilance Module Annual Survey -- Acute Care Facility	Form	Modified
183582	57.200 Healthcare Personnel Safety Component Facility Survey	Form	Modified	Healthcare Personnel Safety - Annual Facility Survey
183582	57.200 Healthcare Personnel Safety Component Facility Survey	Form	Modified
183579	57.204 Healthcare Worker Demographic Data	Form	Modified	Healthcare Worker Demographic Data
183579	57.204 Healthcare Worker Demographic Data	Form	Modified
183578	57.206 Healthcare Worker Prophylaxis/Treatment	Form	Modified	Healthcare Worker Prophylaxis/Treatment
183578	57.206 Healthcare Worker Prophylaxis/Treatment	Form	Modified
183577	57.205 Exposure to Blood and Body Fluids	Form	Modified	Exposure to Blood/Body Fluids
183577	57.205 Exposure to Blood and Body Fluids	Form	Modified
183576	57.105 Group Contact Information	Form	Modified	Group Contact Information
183576	57.105 Group Contact Information	Form	Modified
183573	57.140 Urinary Tract Infection (UTI) for LTCF	Form and Instruction	Modified	Urinary Tract Infection (UTI) for LTCF
183573	57.140 Urinary Tract Infection (UTI) for LTCF	Form and Instruction	Modified	57.140_LTCF UTI_Form_2022
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	Patient Safety Component-Annual Hospital Survey (changes for 2023)
183572	57.103 Patient Safety Component - Annual Hospital Survey	Form and Instruction	Modified
183570	57.101 Facility Contact Information	Form	Modified	Facility Contact Information
183570	57.101 Facility Contact Information	Form	Modified
183568	57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	Form and Instruction	Modified	Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables
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	Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables
183566	57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables	Form and Instruction	Modified
183565	57.100 NHSN Registration Form	Form	Modified	NHSN Registration Form
183565	57.100 NHSN Registration Form	Form	Modified
183564	57.121 Denominators for Procedure	Form and Instruction	Modified	Denominator for Procedure
183564	57.121 Denominators for Procedure	Form and Instruction	Modified
183563	57.128 Laboratory Identified or CDI MDRO Event	Form	Modified	Laboratory-identified MDRO or CDI Event (with revised GISAB questions)
183563	57.128 Laboratory Identified or CDI MDRO Event	Form and Instruction	Modified	Lab ID Event
183563	57.128 Laboratory Identified or CDI MDRO Event	Form and Instruction	Modified
183562	57.120 Surgical Site Infection (SSI)	Form	Modified	Surgical Site Infection
183562	57.120 Surgical Site Infection (SSI)	Form	Modified
183561	57.126 MDRO or CDI Infection Event	Form	Modified	MDRO or CDI Infection Event (with revised GISAB questions)
183561	57.126 MDRO or CDI Infection Event	Form	Modified	MDRO or CDI Infection Event
183561	57.126 MDRO or CDI Infection Event	Form	Modified
183560	57.503 Denominators for Outpatient Dialysis	Form	Modified	Demominators for Dialysis Event Surveillance
183560	57.503 Denominators for Outpatient Dialysis	Form	Modified
183559	57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	Form	Modified	MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting
183559	57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	Form	Modified
183558	57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)	Form	Modified	Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
183558	57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)	Form	Modified
183557	57.207 Follow-up Laboratory Testing	Form	Modified	Follow-up Laboratory Testing
183557	57.207 Follow-up Laboratory Testing	Form	Modified
183556	57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)	Form	Modified	Denominators for Specialty Care Area (SCA)/Oncology (ONC)
183556	57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)	Form	Modified
183555	57.125 Central Line Insertion Practices Adherence Monitoring Form	Form	Modified	Central Line Insertion Practices Adherence Monitoring (revised GISAB questions)
183555	57.125 Central Line Insertion Practices Adherence Monitoring Form	Form	Modified	Central Line Insertion Practices Adherence Monitoring
183555	57.125 Central Line Insertion Practices Adherence Monitoring Form	Form	Modified
183554	57.116 Denominators for Neonatal Intensive Care Unit (NICU)	Form	Modified	PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)
183554	57.116 Denominators for Neonatal Intensive Care Unit (NICU)	Form	Modified
183551	57.114 Urinary Tract Infection (UTI)	Form and Instruction	Modified	Urinary Tract infection (UTI)
183551	57.114 Urinary Tract Infection (UTI)	Form and Instruction	Modified
183550	57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Form	Modified	HCW Prophylaxis/Treatment-Influenza
183550	57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Form	Modified
183549	57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	Form and Instruction	Modified	Pneumonia (PNEU)
183549	57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	Form and Instruction	Modified
183547	57.502 Dialysis Event	Form and Instruction	Modified	Dialysis Event
183547	57.502 Dialysis Event	Form and Instruction	Modified
183545	57.108 Primary Bloodstream Infection (BSI)	Form and Instruction	Modified	Primary Bloodstream Infection (BSI)
183545	57.108 Primary Bloodstream Infection (BSI)	Form and Instruction	Modified
183544	57.500 Outpatient Dialysis Center Practices Survey	Form and Instruction	Modified	Home Dialysis Center Practices Survey
183544	57.500 Outpatient Dialysis Center Practices Survey	Form and Instruction	Modified
183543	57.203 Healthcare Personnel Safety Reporting Plan	Form	Modified	Healthcare Personnel Safety Monthly Reporting Plan
183543	57.203 Healthcare Personnel Safety Reporting Plan	Form	Modified

ICR Details

OMB Control No: 0920-0666	ICR Reference No: 202301-0920-005
Status: Historical Active	Previous ICR Reference No: 202212-0920-013
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0666
Title: [NCEZID] The National Healthcare Safety Network (NHSN)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/09/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/26/2023
Terms of Clearance: Previous terms continue: Approved consistent with the understanding that CDC will continue to add language to its website and reports that clearly caveats the interpretation of longitudinal trends due to changes in the number and characteristics of participating hospitals, particularly changes driven by Medicare and State-level reporting.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2026	36 Months From Approved	07/31/2023
Responses	6,209,922	0	6,209,922
Time Burden (Hours)	1,693,215	0	1,616,151
Cost Burden (Dollars)	0	0	102,951,422

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Abstract: The National Healthcare Safety Network (NHSN) is a system designed to accumulate, exchange, and integrate relevant information and resources among private and public stakeholders to support local and national efforts to protect patients and promote healthcare safety. Specifically, the data is used to determine the magnitude of various healthcare-associated adverse events and trends in the rates of these events among patients and healthcare workers with similar risks. The data will be used to detect changes in the epidemiology of adverse events resulting from new and current medical therapies and changing risks. This Revision includes form changes that were approved in January 2023 plus forms with additional changes that will be implemented upon approval.

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Authorizing Statute(s): US Code: 42 USC 242m(d) Name of Law: Public Health Service Act
   US Code: 42 USC 242b Name of Law: Public Health Service Act
   US Code: 42 USC 242k Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 52572	08/26/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 24802	04/24/2023
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 81

table that charts list of burden

IC Title	Form No.	Form Name
57.100 NHSN Registration Form	CDC 57.100	NHSN Registration Form
57.101 Facility Contact Information	CDC 57.101	Facility Contact Information
57.103 Patient Safety Component - Annual Hospital Survey	None	Patient Safety Component-Annual Hospital Survey (changes for 2023)
57.104 NHSN Administrator Change Request Form	none	Facility Administrator Change Request
57.105 Group Contact Information	CDC 57.105	Group Contact Information
57.106 Patient Safety Monthly Reporting Plan	57.106	Patient Safety Monthly Reporting Plan
57.108 Primary Bloodstream Infection (BSI)	57.108	Primary Bloodstream Infection (BSI)
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	57.111	Pneumonia (PNEU)
57.112 Ventilator-Associated Event (VAE)	57.112	Ventilator Associated Event (VAE)
57.113 Pediatric Ventilator-Associated Event (PedVAE)	57.113	Pediatric Ventilator-Associated Event (PedVAE)
57.114 Urinary Tract Infection (UTI)	57.114	Urinary Tract infection (UTI)
57.115 Custom Event	CDC 57.115	Custom Event
57.116 Denominators for Neonatal Intensive Care Unit (NICU)	CDC 57.116	PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)	CDC 57.117	Denominators for Specialty Care Area (SCA)/Oncology (ONC)
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)	CDC 57.118	Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
57.120 Surgical Site Infection (SSI)	CDC 57.120	Surgical Site Infection
57.121 Denominators for Procedure	57.121	Denominator for Procedure
57.122 HAI Progress Report State Health Department Survey	CDC 55.122	State Health Department HAI Mandate and Validatyion Survey
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables	57.123	Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	57.124	Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables
57.125 Central Line Insertion Practices Adherence Monitoring Form	CDC 57.125, CDC 57.115	Central Line Insertion Practices Adherence Monitoring ,   Central Line Insertion Practices Adherence Monitoring (revised GISAB questions)
57.126 MDRO or CDI Infection Event	CDC 57.126, 57.126	MDRO or CDI Infection Event ,   MDRO or CDI Infection Event (with revised GISAB questions)
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	CDC 57.127	MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting
57.128 Laboratory Identified or CDI MDRO Event	CDC 57.128 Rev 7, v8.5, 57.128	Lab ID Event ,   Laboratory-identified MDRO or CDI Event (with revised GISAB questions)
57.129_Adult Sepsis_BLANK	57.129	Adult Sepsis_
57.135 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly)	57.135	57.135 Late Onset Sepsis/ Meningitis Denominator Form: Data Table for monthly electronic upload
57.136 Long Term Care Facility Component - Respiratory Tract Infection	57.136	Long-Term Care Facility Component – Respiratory Tract Infection
57.137 Long Term care Facility Component--Annual Facility Survey	CDC 57.137	Long-Term Care Facility Component -- Annual Facility Survey
57.138 Laboratory-Identified MDRO or CDI Event for LTCF	CDC 57.138	Laboratory-identified MDRO or CDI Event for LTCF
57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF	CDC 57.139	MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF
57.140 Urinary Tract Infection (UTI) for LTCF	57.140, 57.140	57.140_LTCF UTI_Form_2022 ,   Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF	CDC 57.141	Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations	CDC 57.142	Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF	CDC 57.143	Prevention Process Measures Monthly Monitoring
57.150 Patient Safety Component -- Annual Facility Survey for LTAC	57.150	Urinary Tract Infection (UTI) for LTCF
57.151 Patient Safety Component -- Annual Facility Survey for IRF	57.151	Patient Safety Component—Annual Facility Survey for IRF
57.200 Healthcare Personnel Safety Component Facility Survey	CDC 57.200	Healthcare Personnel Safety - Annual Facility Survey
57.203 Healthcare Personnel Safety Reporting Plan	CDC 57.203	Healthcare Personnel Safety Monthly Reporting Plan
57.204 Healthcare Worker Demographic Data	CDC 57.204	Healthcare Worker Demographic Data
57.205 Exposure to Blood and Body Fluids	CDC 57.205	Exposure to Blood/Body Fluids
57.206 Healthcare Worker Prophylaxis/Treatment	CDC 57.206	Healthcare Worker Prophylaxis/Treatment
57.207 Follow-up Laboratory Testing	CDC 57.207	Follow-up Laboratory Testing
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	CDC 57.210	HCW Prophylaxis/Treatment-Influenza
57.300 Hemovigilance Module Annual Survey -- Acute Care Facility	CDC 57.300, 57.300	Hemovigilance Module - Annual Survey ,   Hemovigilance Module Annual Survey (with revised GISAB questions)
57.301 Hemovigilance Module Monthly Reporting Plan	57.301	57.301_HV Monthly Reporting Plan_BLANK
57.303 Hemovigilance Module Monthly Reporting Denominators	CDC 57.303	Hemovigilance Module Monthly Reporting Denominators
57.305 Hemovigilance Incident	CDC 57.305	Hemovigilance Module Incident
57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility	57.306, CDC 57.306	Hemovigilance Module Annual Survey - Non-acute Care Facility ,   Hemovigilance Module Annual Facility Survey - Non-acute Care Facilities (with revised GISAB questions)
57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	57.307, CDC 57.307	Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction ,   Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction (with revised GISAB questions)
57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	57.308, CDC 57.308	Hemovigilance Adverse Reaction - Allergic Transfusion Reaction ,   Hemovigilance Module Adverse Reaction Allergic Transfusion Reaction (with revised GISAB questions)
57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	CDC 57.309, CDC 57.309	Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction ,   Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction (with revised GISAB questions)
57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	57.310, CDC 57.310	Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction ,   Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction (with revised GISAB questions)
57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	CDC 57.311, CDC 57.311	Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction ,   57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction (with revised GISAB questions)
57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	57.312, CDC 57.312	Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction ,   Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction (with modified GISAB questions)
57.313 Hemovigilance Adverse Reaction - Infection	57.313, CDC 57.313	Hemovigilance Adverse Reaction - Infection ,   Hemovigilance Adverse Reaction - Infection (with revised GISAB questions)
57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura	57.314, CDC 57.314	Hwemovilgilance Adverse Reaction - Post Transfusion Purpura ,   Hemovigilance Adverse Reaction - Post Transfusion Purpura (with revised GISAB questions)
57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	CDC 57.315, CDC 57.315	Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea ,   Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea (with revised GISAB questions)
57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease	CDC 57.316, CDC 57.316	Hemovigilance Adverse Reaction - Transfusin Associated Graft vs. Host Disease ,   Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease (with revised GISAB questions)
57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury	57.317, CDC 57.317	Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury ,   Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury (with revised GISAB questions)
57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	CDC 57.318, 57.318	Hemoviligance Adverse Reaction - Transfusion Associated Circulatory Overload ,   Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload (with revised GISAB questions)
57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	CDC 57.319, CDC 57.319	Hemovigilance Adverse Reaction - Unknown Transfusion Reaction ,   Hemovigilance Adverse Reaction - Unknown Transfusion Reaction (with modified GISAB questions)
57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	CDC 57.320, 57.320	Hemovigilance Adverse Reaction - Other Transfusion Reaction ,   Hemovigilance Adverse Reaction - Other Transfusion Reaction (with revised GISAB questions)
57.400 Outpatient Procedure - Annual Facility Survey	CDC 57.400	Outpatient Procedure Component - Annual Facility Survey
57.401 Outpatient Procedure - Monthly Reporting Plan	CDC 57.401	Outpatient Procedure Component - Monthly Reporting Plan
57.402 Outpatient Procedure Component Event	CDC 57.402	Outpatient Procedure - Component Event
57.403 Outpatient Procedure Component - Monthly Denominators and Summary	CDC 57.403	Outpatient Procedure - Monthly Denominators and Summary
57.404 Outpatient Procedure Component - SSI Denominators	57.404	Outpatient Procedure Component - SSI Denominators
57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event	CDC 57.405	Outpatient Procedure Component - SSI Denominators
57.500 Outpatient Dialysis Center Practices Survey	57.500	Home Dialysis Center Practices Survey
57.501 Dialysis Monthly Reporting Plan	CDC 57.501	NHSN Registration Form
57.502 Dialysis Event	CDC 57.502	Dialysis Event
57.503 Denominators for Outpatient Dialysis	CDC 57.503	Demominators for Dialysis Event Surveillance
57.504 Prevention Process Measures Monthly Monitoring for Dialysis	CDC 57.504	Prevention Process Measures Monthly Monitoring for Dialysis
57.505 Dialysis Patient Influenza Vaccination	CDC 57.505	Dialysis Patient Influenza Vaccination
57.506 Dialysis Patient Influenza Vaccination Denominator	CDC 57.506	Dialysis Patient Influenza Vaccination Denominator
57.507 Home Dialysis Center Practices Survey	57.507, 57.507	57.507 Home Dialysis Center Practices Survey ,   57.507_dialhomesurv_2020_final
Annual Healthcare Personnel Influenza Vaccination Summary	0920-0666	Annual Healthcare Personnel Influenza Vaccination Summary
Monthly Survey Patient Days & Nurse Staffing	None, NA	Monthly Survey Patient Days & Nurse Staffing ,   Monthly Survey Patient Days & Nurse Staffing
Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	0920-0666	Weekly HCP Influenza Vaccination Cumulative Summary for Long-Term Care Facilities
Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities	0920-0666	Weekly HCP Influenza Vaccination Cumulative Summary Non-Long-Term Care Facilities
Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	0920-0666	Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	6,209,922	6,209,922	0	0	0	0
Annual Time Burden (Hours)	1,693,215	1,616,151	0	77,064	0	0
Annual Cost Burden (Dollars)	0	102,951,422	0	-102,951,422	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This Revision includes changes previously approved in January 2023 (Emergency Revision), and these changes will be continued. This Revision also includes new changes to 31 forms that increase response burden by one minute per form/response. The changes to the Gender Identify and Sex at Birth questions will be phased in during 2023-2024. Finally, this Revision includes a substantial reduction in burden cost. Per HHS guidance the information presented in table SSA.12-B has been zeroed out in ROCIS entries for burden cost. The revised estimate for burden cost is based on the information presented in SSA.13.

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Annual Cost to Federal Government: $18,045,604

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/26/2023

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