[NCEZID] The National Healthcare Safety Network (NHSN)

Forms and Documents

Document Name	Status
Form 57.106 57.106 Patient Safety Monthly Reporting Plan Form and Instruction	Unchanged
Form 57.701 57.701 - Glycemic Control Module-HYPO Annual Survey Form and Instruction	New
Form 57.700 57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist Form and Instruction	New
Form 57.700 57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance Form and Instruction	New
Form 57.700 57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Initial Set up Form and Instruction	New
Form 57.600 57.600 - Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist Form and Instruction	New
Form 57.600 57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist Form and Instruction	New
Form 57.600 57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance Form and Instruction	New
Form 57.600 57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up Form and Instruction	New
Form 57.145 57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA Form and Instruction	New
Form 57.144 57.144 - Long Term Care Respiratory Tract Infections (RTI) Module Form and Instruction	New
Form 57.133 57.133 - Patient Safety Component FHIR Measures-VTE Module- Infection Preventionist Form and Instruction	New
Form 57.133 57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Yearly Maintenance Form and Instruction	New
Form 57.133 57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Initial Set up Form and Instruction	New
Form 57.132 57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist Form and Instruction	New
Form 57.132 57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Yearly Maintenance Form and Instruction	New
Form 57.132 57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Initial Set up Form and Instruction	New
Form 57.130 57.130 - Patient Safety Component CSV Data Collection-Infection Preventionist CSV Data Collection-Infection Preventionist Form and Instruction	New
Form 57.130 57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS)-Infection Preventionist Form and Instruction	New
Form 57.130 57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Yearly Maintenance Form and Instruction	New
Form 57.130 57.130 Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Initial Set up Form and Instruction	New
Monthly Survey Patient Days & Nurse Staffing Form and Instruction	Unchanged
Form 0920-0666 Annual Healthcare Personnel Influenza Vaccination Summary Form and Instruction	Unchanged
Form 0920-0666 Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	Unchanged
Form 0920-0666 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	Modified
Form 0920-0666 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities Form and Instruction	Unchanged
Form 57.135 57.135 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) Form and Instruction	Unchanged
Form 57.136 57.136 Long Term Care Facility Component - Respiratory Tract Infection Form and Instruction	Unchanged
57.104 NHSN Administrator Change Request Form Form and Instruction	Unchanged
Form CDC 55.122 57.122 HAI Progress Report State Health Department Survey Form	Unchanged
Form CDC 57.405 57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Form	Modified
Form 57.404 57.404 Outpatient Procedure Component - SSI Denominators Form	Modified
Form 57.507 57.507 Home Dialysis Center Practices Survey Form	Modified
Form 57.320 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction Form	Unchanged
Form CDC 57.319 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction Form	Unchanged
Form 57.318 57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload Form	Unchanged
Form 57.317 57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury Form	Unchanged
Form CDC 57.316 57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease Form	Unchanged
Form CDC 57.315 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea Form	Modified
Form 57.314 57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura Form	Unchanged
Form 57.313 57.313 Hemovigilance Adverse Reaction - Infection Form	Unchanged
Form 57.312 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction Form	Unchanged
Form CDC 57.311 57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction Form	Unchanged
Form 57.310 57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction Form	Unchanged
Form CDC 57.309 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction Form	Unchanged
Form 57.308 57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction Form	Unchanged
Form 57.307 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction Form	Unchanged
Form 57.306 57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility Form	Unchanged
Form 57.129 57.129_Adult Sepsis_BLANK Form	Unchanged
Form CDC 57.115 57.115 Custom Event Form	Unchanged
Form 57.113 57.113 Pediatric Ventilator-Associated Event (PedVAE) Form and Instruction	Unchanged
Form CDC 57.506 57.506 Dialysis Patient Influenza Vaccination Denominator Form	Unchanged
Form CDC 57.505 57.505 Dialysis Patient Influenza Vaccination Form	Unchanged
Form CDC 57.504 57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form	Unchanged
Form CDC 57.501 57.501 Dialysis Monthly Reporting Plan Form	Modified
Form CDC 57.403 57.403 Outpatient Procedure Component - Monthly Denominators and Summary Form	Modified
Form CDC 57.402 57.402 Outpatient Procedure Component Event Form	Modified
Form CDC 57.401 57.401 Outpatient Procedure - Monthly Reporting Plan Form	Modified
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey Form	Modified
Form 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form and Instruction	Modified
Form 57.150 57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form and Instruction	Modified
Form CDC 57.143 57.143 Prevention Process Measures Monthly Monitoring for LTCF Form	Modified
Form CDC 57.142 57.142 Denominators for LTCF Locations Form	Modified
Form CDC 57.141 57.141 Monthly Reporting Plan for LTCF Form	Modified
Form 57.112 57.112 Ventilator-Associated Event (VAE) Form and Instruction	Unchanged
Form CDC 57.139 57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Form	Modified
Form CDC 57.138 57.138 Laboratory-Identified MDRO or CDI Event for LTCF Form	Modified
Form CDC 57.137 57.137 Long Term care Facility Component--Annual Facility Survey Form	Modified
Form CDC 57.305 57.305 Hemovigilance Incident Form	Unchanged
Form CDC 57.303 57.303 Hemovigilance Module Monthly Reporting Denominators Form and Instruction	Modified
Form 57.301 57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction	Unchanged
Form CDC 57.300 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form	Unchanged
Form CDC 57.200 57.200 Healthcare Personnel Safety Component Facility Survey Form	Unchanged
Form CDC 57.204 57.204 Healthcare Worker Demographic Data Form	Unchanged
Form CDC 57.206 57.206 Healthcare Worker Prophylaxis/Treatment Form	Unchanged
Form CDC 57.205 57.205 Exposure to Blood and Body Fluids Form	Unchanged
Form CDC 57.105 57.105 Group Contact Information Form	Unchanged
Form 57.140 57.140 Urinary Tract Infection (UTI) for LTCF Form and Instruction	Modified
Form 57.103 57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction	Modified
Form CDC 57.101 57.101 Facility Contact Information Form	Unchanged
Form 57.124 57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Form and Instruction	Modified
Form 57.123 57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Form and Instruction	Modified
Form CDC 57.100 57.100 NHSN Registration Form Form	Unchanged
Form 57.121 57.121 Denominators for Procedure Form and Instruction	Modified
Form CDC 57.128 Rev 7, 57.128 Laboratory Identified or CDI MDRO Event Form and Instruction	Unchanged
Form CDC 57.120 57.120 Surgical Site Infection (SSI) Form	Modified
Form CDC 57.126 57.126 MDRO or CDI Infection Event Form	Unchanged
Form CDC 57.503 57.503 Denominators for Outpatient Dialysis Form	Modified
Form CDC 57.127 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form	Unchanged
Form CDC 57.118 57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Form	Unchanged
Form CDC 57.207 57.207 Follow-up Laboratory Testing Form	Unchanged
Form CDC 57.117 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form	Unchanged
Form CDC 57.125 57.125 Central Line Insertion Practices Adherence Monitoring Form Form	Unchanged
Form CDC 57.116 57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form	Unchanged
Form 57.114 57.114 Urinary Tract Infection (UTI) Form and Instruction	Unchanged
Form CDC 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form	Unchanged
Form 57.111 57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Form and Instruction	Unchanged
Form CDC 57.502 57.502 Dialysis Event Form and Instruction	Modified
Form 57.108 57.108 Primary Bloodstream Infection (BSI) Form and Instruction	Unchanged
Form 57.500 57.500 Outpatient Dialysis Center Practices Survey Form and Instruction	Modified
Form CDC 57.203 57.203 Healthcare Personnel Safety Reporting Plan Form	Unchanged
FHIR Measures Data Dictionary _HOB, HT-CDI, VTE, LOSMEN, Hypo.xlsx Supplementary Document	2023-11-14
FHIR Measures Data Dictionary (RPS)_09_27_2023.xlsx Supplementary Document	2023-11-14
H. Privacy Impact Assessment.pdf Supplementary Document	2023-11-14
G2. NHSN 308d Request for Extension and Ammendment.docx Supplementary Document	2023-11-14
G1. NHSN 308d Approval 2015.pdf Supplementary Document	2023-11-14
F3. Human Subjects Determination.pdf Supplementary Document	2023-11-14
F2. Report of End of Human Research Review 0.1253.docx Supplementary Document	2023-11-14
F1. Closure CDC Protocol # 4062.docx Supplementary Document	2023-11-14
D. Explanation for Program Changes or Adjustments.docx Supplementary Document	2023-11-14
B. Published 60-Day Federal Register.pdf Supplementary Document	2023-11-14
A3. 42 USC 242m.pdf Supplementary Document	2023-11-14
A2. 42 USC 242k.pdf Supplementary Document	2023-11-14
A1. 42 USC 242b.pdf Supplementary Document	2023-11-14
2024 NHIS SSB 2023-11-8-2023.docx Supporting Statement B	2023-11-14
Supporting Statement A 0920-0666 October 2023_final.docx Supporting Statement A	2023-11-16

IC Document Collections

IC ID	Document Title	Status
7134	57.106 Patient Safety Monthly Reporting Plan Form and Instruction	Unchanged
263469	Billing Code Data: 837I Upload Other-Template	New
263468	57.701 - Glycemic Control Module-HYPO Annual Survey Form and Instruction	New
263467	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist Form and Instruction	New
263466	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance Form and Instruction	New
263465	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Initial Set up Form and Instruction	New
263464	57.600 - Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist Form and Instruction	New
263463	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist Form and Instruction	New
263462	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance Form and Instruction	New
263461	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up Form and Instruction	New
263460	57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA Form and Instruction	New
263459	57.144 - Long Term Care Respiratory Tract Infections (RTI) Module Form and Instruction	New
263458	57.133 - Patient Safety Component FHIR Measures-VTE Module- Infection Preventionist Form and Instruction	New
263457	57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Yearly Maintenance Form and Instruction	New
263454	57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Initial Set up Form and Instruction	New
263453	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist Form and Instruction	New
263452	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Yearly Maintenance Form and Instruction	New
263450	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Initial Set up Form and Instruction	New
263449	57.130 - Patient Safety Component CSV Data Collection-Infection Preventionist CSV Data Collection-Infection Preventionist Form and Instruction	New
263448	57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS)-Infection Preventionist Form and Instruction	New
263447	57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Yearly Maintenance Form and Instruction	New
263439	57.130 Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Initial Set up Form and Instruction	New
257463	Monthly Survey Patient Days & Nurse Staffing Form and Instruction	Unchanged
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	Modified
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	Unchanged
222906	57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction Form	Unchanged
222905	57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload Form	Unchanged
222904	57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury Form	Unchanged
222903	57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease Form	Unchanged
222902	57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea Form	Modified
222901	57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura Form	Unchanged
222900	57.313 Hemovigilance Adverse Reaction - Infection Form	Unchanged
222899	57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction Form	Unchanged
222898	57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction Form	Unchanged
222897	57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction Form	Unchanged
222896	57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction Form	Unchanged
222895	57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction Form	Unchanged
222894	57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction Form	Unchanged
222893	57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility Form	Unchanged
222892	57.129_Adult Sepsis_BLANK Form	Unchanged
222891	57.115 Custom Event Form	Unchanged
222890	57.113 Pediatric Ventilator-Associated Event (PedVAE) Form and Instruction	Unchanged
208411	57.506 Dialysis Patient Influenza Vaccination Denominator Form	Unchanged
208410	57.505 Dialysis Patient Influenza Vaccination Form	Unchanged
208409	57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form	Unchanged
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	Unchanged
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	Unchanged
190363	57.303 Hemovigilance Module Monthly Reporting Denominators Form and Instruction	Modified
190361	57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction	Unchanged
190360	57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form	Unchanged
183582	57.200 Healthcare Personnel Safety Component Facility Survey Form	Unchanged
183579	57.204 Healthcare Worker Demographic Data Form	Unchanged
183578	57.206 Healthcare Worker Prophylaxis/Treatment Form	Unchanged
183577	57.205 Exposure to Blood and Body Fluids Form	Unchanged
183576	57.105 Group Contact Information Form	Unchanged
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	Unchanged
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	Unchanged
183564	57.121 Denominators for Procedure Form and Instruction	Modified
183563	57.128 Laboratory Identified or CDI MDRO Event Form and Instruction	Unchanged
183562	57.120 Surgical Site Infection (SSI) Form	Modified
183561	57.126 MDRO or CDI Infection Event Form	Unchanged
183560	57.503 Denominators for Outpatient Dialysis Form	Modified
183559	57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form	Unchanged
183558	57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Form	Unchanged
183557	57.207 Follow-up Laboratory Testing Form	Unchanged
183556	57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form	Unchanged
183555	57.125 Central Line Insertion Practices Adherence Monitoring Form Form	Unchanged
183554	57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form	Unchanged
183551	57.114 Urinary Tract Infection (UTI) Form and Instruction	Unchanged
183550	57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form	Unchanged
183549	57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Form and Instruction	Unchanged
183547	57.502 Dialysis Event Form and Instruction	Modified
183545	57.108 Primary Bloodstream Infection (BSI) Form and Instruction	Unchanged
183544	57.500 Outpatient Dialysis Center Practices Survey Form and Instruction	Modified
183543	57.203 Healthcare Personnel Safety Reporting Plan Form	Unchanged

ICR Details

OMB Control No: 0920-0666	ICR Reference No: 202310-0920-013
Status: Received in OIRA	Previous ICR Reference No: 202301-0920-005
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	Date Submitted to OIRA: 11/17/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2026
Responses	5,271,534	6,209,922
Time Burden (Hours)	2,434,196	1,693,215
Cost Burden (Dollars)	0	0

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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 changes made to approved collection forms and 9 new forms.

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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:
	88 FR 56827	08/21/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 78364	11/15/2023
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 102

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	57.103	Patient Safety Component-Annual Hospital Survey
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_
57.130 - Patient Safety Component CSV Data Collection-Infection Preventionist CSV Data Collection-Infection Preventionist	57.130	Reporting Plan - Respiratory Pathogens Surveillance (RPS)
57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Yearly Maintenance	57.130	Reporting Plan - Respiratory Pathogens Surveillance (RPS)
57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS)-Infection Preventionist	57.130	Reporting Plan - Respiratory Pathogens Surveillance (RPS)
57.130 Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Initial Set up	57.130	Reporting Plan - Respiratory Pathogens Surveillance (RPS)
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Initial Set up	57.132	Reporting Plan HOB and HTCDI
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Yearly Maintenance	57.132	Reporting Plan HOB and HTCDI
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist	57.132	Reporting Plan HOB and HTCDI
57.133 - Patient Safety Component FHIR Measures-VTE Module- Infection Preventionist	57.133	Reporting Plan Venous Thromboembolism
57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Initial Set up	57.133	Reporting Plan Venous Thromboembolism
57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Yearly Maintenance	57.133	Reporting Plan Venous Thromboembolism
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	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
57.144 - Long Term Care Respiratory Tract Infections (RTI) Module	57.144	Long-Term Care RTI Module
57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA	57.145	LTC-AU Module
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	57.318, CDC 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	57.320, CDC 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
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up	57.600	Reporting Plan LOSMEN
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance	57.600	Reporting Plan LOSMEN
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist	57.600	Reporting Plan LOSMEN
57.600 - Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist	57.600	Reporting Plan LOSMEN
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Initial Set up	57.700	Reporting Plan Glycemic Control Module Hypoglycemia
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance	57.700	Reporting Plan Glycemic Control Module Hypoglycemia
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist	57.700	Reporting Plan Glycemic Control Module Hypoglycemia
57.701 - Glycemic Control Module-HYPO Annual Survey	57.701	Glycemic Control module Hypo-Annual Hospital Survey
Annual Healthcare Personnel Influenza Vaccination Summary	0920-0666	Annual Healthcare Personnel Influenza Vaccination Summary
Billing Code Data: 837I Upload
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

	Total Request	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	5,271,534	6,209,922	0	-938,388	0	0
Annual Time Burden (Hours)	2,434,196	1,693,215	0	740,981	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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: Yes

Burden Reduction Due to: Changing Forms

Short Statement: Burden changes are due to modifications to instruments and addition of instruments.

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Annual Cost to Federal Government: $49,992,135

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: 11/17/2023

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