57.137 Long Term care Facility Component--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⚠️ Notice: This information collection may be referencing outdated material.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 57.137 57.137 Long Term care Facility Component--Annual Facility Survey Form
CDC 57.137 Long-Term Care Facility Component -- Annual Facility Sur 57.137 Long-Term Care Facility Component Annual Facility Survey-Clean Form.docx Form
CDC 57.137 Long-Term Care Facility Component -- Annual Facility Sur 57.137 Long-Term Care Facility Component Annual Facility Survey-Clean Form.docx Form

Information Collection (IC) Details

IC Title:	57.137 Long Term care Facility Component--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 57.137	Long-Term Care Facility Component -- Annual Facility Survey	57.137 Long-Term Care Facility Component Annual Facility Survey-Clean Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17,700	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 %

	Requested	Previously Approved
Annual Number of Responses for this IC	17,700	17,700
Annual IC Time Burden (Hours)	35,400	35,400
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.