OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

[NCEZID] The National Healthcare Safety Network (NHSN)

ICR 202301-0920-005 · OMB 0920-0666 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
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 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 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 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
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 57.405 57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Form Modified Repair queued
Form 57.404 57.404 Outpatient Procedure Component - SSI Denominators Form Modified Missing upstream
Form 57.507 57.507 Home Dialysis Center Practices Survey Form Modified Missing upstream
Form 57.320 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction Form Modified Repair queued
Form CDC 57.319 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction Form Modified Missing upstream
Form 57.318 57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload Form Modified Missing upstream
Form 57.317 57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury Form Modified Repair queued
Form CDC 57.316 57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease Form Modified Repair queued
Form CDC 57.315 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea Form Modified Repair queued
Form 57.314 57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura Form Modified Missing upstream
Form 57.313 57.313 Hemovigilance Adverse Reaction - Infection Form Modified Repair queued
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 Form Modified Repair queued
Form 57.310 57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction Form Modified Repair queued
Form CDC 57.309 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction Form Modified Repair queued
Form 57.308 57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction Form Modified Repair queued
Form 57.307 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction Form Modified Repair queued
Form 57.306 57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility Form Modified Repair queued
Form 57.129 57.129_Adult Sepsis_BLANK Form Modified Repair queued
Form CDC 57.115 57.115 Custom Event Form Modified Missing upstream
Form 57.113 57.113 Pediatric Ventilator-Associated Event (PedVAE) Form and Instruction Modified Repair queued
Form CDC 57.506 57.506 Dialysis Patient Influenza Vaccination Denominator Form Modified Repair queued
Form CDC 57.505 57.505 Dialysis Patient Influenza Vaccination 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 57.501 Dialysis Monthly Reporting Plan Form Modified Repair queued
Form CDC 57.403 57.403 Outpatient Procedure Component - Monthly Denominators and Summary Form Modified Repair queued
Form CDC 57.402 57.402 Outpatient Procedure Component Event Form Modified Repair queued
Form CDC 57.401 57.401 Outpatient Procedure - Monthly Reporting Plan Form Modified Repair queued
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey Form Modified Repair queued
Form 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form and Instruction Modified Repair queued
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 Modified Repair queued
Form CDC 57.142 57.142 Denominators for LTCF Locations Form Modified Repair queued
Form CDC 57.141 57.141 Monthly Reporting Plan for LTCF Form Modified Repair queued
Form 57.112 57.112 Ventilator-Associated Event (VAE) Form and Instruction Modified Repair queued
Form CDC 57.139 57.139 MDRO and CDI Prevention Process Measures Monthly 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 57.137 Long Term care Facility Component--Annual Facility Survey Form Modified Repair queued
Form CDC 57.305 57.305 Hemovigilance Incident Form Modified Repair queued
Form CDC 57.303 57.303 Hemovigilance Module Monthly Reporting Denominators Form Modified Repair queued
Form 57.301 57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction Modified Repair queued
Form CDC 57.300 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form Modified Repair queued
Form CDC 57.200 57.200 Healthcare Personnel Safety Component Facility Survey Form Modified Missing upstream
Form CDC 57.204 57.204 Healthcare Worker Demographic Data Form Modified Repair queued
Form CDC 57.206 57.206 Healthcare Worker Prophylaxis/Treatment Form Modified Repair queued
Form CDC 57.205 57.205 Exposure to Blood and Body Fluids Form Modified Repair queued
Form CDC 57.105 57.105 Group Contact Information Form Modified Missing upstream
Form 57.140 57.140 Urinary Tract Infection (UTI) for LTCF Form and Instruction Modified Repair queued
57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction Modified Repair queued
Form CDC 57.101 57.101 Facility Contact Information Form 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 CDC 57.100 57.100 NHSN Registration Form Form Modified Repair queued
Form 57.121 57.121 Denominators for Procedure Form and Instruction Modified Repair queued
Form CDC 57.128 Rev 7, 57.128 Laboratory Identified or CDI MDRO Event Form and Instruction Modified Repair queued
Form CDC 57.120 57.120 Surgical Site Infection (SSI) Form Modified Available
Form CDC 57.126 57.126 MDRO or CDI Infection Event Form Modified Repair queued
Form CDC 57.503 57.503 Denominators for Outpatient Dialysis Form Modified Repair queued
Form CDC 57.127 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form Modified Repair queued
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 57.207 Follow-up Laboratory Testing Form Modified Repair queued
Form CDC 57.117 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form Modified Repair queued
Form CDC 57.125 57.125 Central Line Insertion Practices Adherence Monitoring Form Form Modified Repair queued
Form CDC 57.116 57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form Modified Repair queued
Form 57.114 57.114 Urinary Tract Infection (UTI) Form and Instruction Modified Repair queued
Form CDC 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form Modified Repair queued
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 57.502 Dialysis Event 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 CDC 57.203 57.203 Healthcare Personnel Safety Reporting Plan Form Modified Missing upstream
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 Missing upstream
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 Missing upstream
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 Missing upstream
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
IC IDCollectionTypeStatusForm
7134 57.106 Patient Safety Monthly Reporting Plan Form and Instruction Modified
257463 Monthly Survey Patient Days & Nurse Staffing Form and Instruction Modified
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
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
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
237430 57.104 NHSN Administrator Change Request Form Form and Instruction 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 Modified
228153 57.404 Outpatient Procedure Component - SSI Denominators Form Modified
222908 57.507 Home Dialysis Center Practices Survey Form Modified
222907 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction Form Modified
222906 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction Form Modified
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
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
222901 57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura Form Modified
222900 57.313 Hemovigilance Adverse Reaction - Infection Form Modified
222899 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction Form Modified
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
222896 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction Form Modified
222895 57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction Form Modified
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
222892 57.129_Adult Sepsis_BLANK Form Modified
222891 57.115 Custom Event Form Modified
222890 57.113 Pediatric Ventilator-Associated Event (PedVAE) Form and Instruction Modified
208411 57.506 Dialysis Patient Influenza Vaccination Denominator Form Modified
208410 57.505 Dialysis Patient Influenza Vaccination Form Modified
208409 57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form Modified
208408 57.501 Dialysis Monthly Reporting Plan Form Modified
208407 57.403 Outpatient Procedure Component - Monthly Denominators and Summary Form Modified
208406 57.402 Outpatient Procedure Component Event Form Modified
208405 57.401 Outpatient Procedure - Monthly Reporting Plan Form Modified
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
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
200379 57.142 Denominators for LTCF Locations Form Modified
200378 57.141 Monthly Reporting Plan for LTCF Form Modified
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
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
190364 57.305 Hemovigilance Incident Form Modified
190363 57.303 Hemovigilance Module Monthly Reporting Denominators Form Modified
190361 57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction Modified
190360 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form Modified
183582 57.200 Healthcare Personnel Safety Component Facility Survey Form Modified
183579 57.204 Healthcare Worker Demographic Data Form Modified
183578 57.206 Healthcare Worker Prophylaxis/Treatment Form Modified
183577 57.205 Exposure to Blood and Body Fluids Form Modified
183576 57.105 Group Contact Information Form 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
183570 57.101 Facility Contact Information Form 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
183565 57.100 NHSN Registration Form Form Modified
183564 57.121 Denominators for Procedure Form and Instruction Modified
183563 57.128 Laboratory Identified or CDI MDRO Event Form and Instruction Modified
183562 57.120 Surgical Site Infection (SSI) Form Modified
183561 57.126 MDRO or CDI Infection Event Form Modified
183560 57.503 Denominators for Outpatient Dialysis Form Modified
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
183557 57.207 Follow-up Laboratory Testing Form Modified
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
183554 57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form Modified
183551 57.114 Urinary Tract Infection (UTI) Form and Instruction Modified
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
183547 57.502 Dialysis Event 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
183543 57.203 Healthcare Personnel Safety Reporting Plan Form Modified
ICR Details
StatusReceived in OIRA
Agency/SubagencyHHS/CDC
OMB Control No0920-0666
Type of Information CollectionRevision of a currently approved collection
Previous ICR Reference No202212-0920-013
Agency Tracking No0920-0666
Date Submitted to OIRA1969-12-31
Requested Expiration Date1969-12-31