57.400 Outpatient Procedure - Annual Facility 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⚠️ Notice: This information collection may be referencing outdated material.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 CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey Form
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

IC Title:	57.400 Outpatient Procedure - Annual Facility 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	CDC 57.400	Outpatient Procedure Component - Annual Facility Survey	57.400_ASCFacSurv_BLANK.DOCX		Yes	Yes	Fillable Fileable

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	Previously Approved
Annual Number of Responses for this IC	350	350
Annual IC Time Burden (Hours)	58	58
Annual IC Cost Burden (Dollars)	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.