57.103 Patient Safety Component - Annual Hospital Survey

[NCEZID] The National Healthcare Safety Network (NHSN)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 57.103 57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction
Form 57.103 57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction
57.103 Patient Safety Component-Annual Hospital Survey 57.103_ACH Annual Facility Survey-Clean Version.docx Form and Instruction
57.103 Patient Safety Component-Annual Hospital Survey 57.103_ACH Annual Facility Survey-Clean Version.docx Form and Instruction

Information Collection (IC) Details

IC Title:	57.103 Patient Safety Component - Annual Hospital Survey	Agency IC Tracking Number:	0920-0666

Is this a Common Form? No		IC Status: Unchanged

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 and Instruction	57.103	Patient Safety Component-Annual Hospital Survey	57.103_ACH Annual Facility Survey-Clean Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,311	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	Previously Approved
Annual Number of Responses for this IC	5,311	5,311
Annual IC Time Burden (Hours)	11,950	11,950
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.