Information Collection

57.203 Healthcare Personnel Safety Reporting Plan

IC 183543 under ICR 202301-0920-005 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC 57.203 57.203 Healthcare Personnel Safety Reporting Plan	Form
CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan 57.203_HCPSafetyPlan_BLANK.docx	Form
CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan 57.203_HCPSafetyPlan_BLANK.docx	Form
12. Healthcare Personnel Exposure.pdf Att G12_Healthcare Personnel Exposure	IC Document
12. Healthcare Personnel Exposure.pdf Att G12_Healthcare Personnel Exposure	IC Document

IC Title:

57.203 Healthcare Personnel Safety Reporting Plan

Agency IC Tracking Number:

0920-0666

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CDC 57.203	Healthcare Personnel Safety Monthly Reporting Plan	57.203_HCPSafetyPlan_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 19,500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	19,500	0	19,500
Annual IC Time Burden (Hours)	0	0	0
Annual IC Cost Burden (Dollars)	0	-54,834	54,834

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att G12_Healthcare Personnel Exposure	12. Healthcare Personnel Exposure.pdf	09/25/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.