Information Collection

57.114 Urinary Tract Infection (UTI)

IC 183551 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⚠️ Notice: This information collection may be referencing outdated material.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 57.114 57.114 Urinary Tract Infection (UTI)	Form and Instruction
57.114 Urinary Tract infection (UTI) 57.114_UTI_BLANK_November_2022.docx	Form and Instruction
57.114 Urinary Tract infection (UTI) 57.114_UTI_BLANK_November_2022.docx	Form and Instruction
57.114_UTI_BLANK_November_2022.docx 57.114 UTI form with GISAB edits in tracked changes	IC Document
57.114_UTI_BLANK_November_2022.docx 57.114 UTI form with GISAB edits in tracked changes	IC Document

IC Title:

57.114 Urinary Tract Infection (UTI)

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 and Instruction	57.114	Urinary Tract infection (UTI)	57.114_UTI_BLANK_November_2022.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,000

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	30,000	0	30,000
Annual IC Time Burden (Hours)	10,500	500	10,000
Annual IC Cost Burden (Dollars)	0	-396,600	396,600

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
57.114 UTI form with GISAB edits in tracked changes	57.114_UTI_BLANK_November_2022.docx	04/25/2023

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