Information Collection

57.140 Urinary Tract Infection (UTI) for LTCF

IC 183573 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⚠️ Notice: This information collection may be referencing outdated material.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 57.140 57.140 Urinary Tract Infection (UTI) for LTCF	Form and Instruction
57.140 57.140_LTCF UTI_Form_2022 57.140_LTCF_UTI_Form_edits_for_2022[1].docx	Form and Instruction
57.140 57.140_LTCF UTI_Form_2022 57.140_LTCF_UTI_Form_edits_for_2022[1].docx	Form and Instruction
57.140 Urinary Tract Infection (UTI) for LTCF 57.140_UTI_LTCF_BLANK.docx	Form and Instruction
57.140 Urinary Tract Infection (UTI) for LTCF 57.140_UTI_LTCF_BLANK.docx	Form and Instruction

IC Title:

57.140 Urinary Tract Infection (UTI) for LTCF

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	57.140	57.140_LTCF UTI_Form_2022	57.140_LTCF_UTI_Form_edits_for_2022[1].docx		Yes	Yes	Fillable Fileable
Form and Instruction	57.140	Urinary Tract Infection (UTI) for LTCF	57.140_UTI_LTCF_BLANK.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: 339

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	12,204	0	12,204
Annual IC Time Burden (Hours)	7,119	0	7,119
Annual IC Cost Burden (Dollars)	0	-282,340	282,340

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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