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57.400 Outpatient Procedure - Annual Facility Survey
[NCEZID] The National Healthcare Safety Network (NHSN)
OMB: 0920-0666
IC ID: 208404
OMB.report
HHS/CDC
OMB 0920-0666
ICR 202310-0920-013
IC 208404
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:
2024-02-28 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Form CDC 57.400
57.400 Outpatient Procedure - Annual Facility Survey
Form
CDC 57.400 Outpatient Procedure Component - Annual Facility Survey
57.400_ASCFacSurv_BLANK.DOCX
Form
CDC 57.400 Outpatient Procedure Component - Annual Facility Survey
57.400_ASCFacSurv_BLANK.DOCX
Form
G17. Outpatient Procedure Component.pdf
Att G17_Outpatient Procedure Component
IC Document
G17. Outpatient Procedure Component.pdf
Att G17_Outpatient Procedure Component
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
57.400 Outpatient Procedure - Annual Facility Survey
Agency IC Tracking Number:
0920-0666
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CDC 57.400
Outpatient Procedure Component - Annual Facility Survey
57.400_ASCFacSurv_BLANK.DOCX
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
350
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
350
0
-350
0
0
700
Annual IC Time Burden (Hours)
58
0
-59
0
0
117
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Att G17_Outpatient Procedure Component
G17. Outpatient Procedure Component.pdf
08/08/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.