[NCEZID] The National Healthcare Safety Network (NHSN)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 57.106 Patient Safety Monthly Reporting Plan	Form and Instruction	Modified	Available
Form 57.106 57.106 Patient Safety Monthly Reporting Plan	Form and Instruction	Modified	Repair queued
Form 57.803 All Hazards	Form and Instruction	New	Available
Form 57.803 All Hazards	Form and Instruction	New	Repair queued
Form 57.802 Bed Capacity-IT Initial Set Up	Form and Instruction	New	Available
Form 57.802 Bed Capacity-IT Initial Set Up	Form and Instruction	New	Repair queued
Form 57.801 External Validation Summary Report	Form and Instruction	New	Available
Form 57.801 External Validation Summary Report	Form and Instruction	New	Repair queued
Form 57.215 Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel	Form and Instruction	New	Available
Form 57.215 Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel	Form and Instruction	New	Repair queued
Form 57.214 CSV Submission	Form	New	Available
Form 57.214 Annual Healthcare Personnel Influenza Vaccination Summary (CSV)	Form	New	Repair queued
Form 57.211 CSV Submission	Form	New	Available
Form 57.211 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities (CSV)	Form	New	Repair queued
Form 57.133 Patient Safety Attestation	Form and Instruction	New	Available
Form 57.133 Patient Safety Attestation	Form and Instruction	New	Repair queued
Form 57.130 Pathogens of High Consequence	Form and Instruction	New	Available
Form 57.130 Pathogens of High Consequence	Form and Instruction	New	Repair queued
Form 57.124 Yearly Maintenance (form not used)	Form	New	Available
Form 57.124 AUR Pharmacy Data Electronic Upload Specification Tables (Yearly Maintenance)	Form	New	Repair queued
Form 57.124 Initial Set-up (form not used)	Form	New	Available
Form 57.124 AUR Pharmacy Data Electronic Upload Specification Tables (Initial Set-up)	Form	New	Repair queued
Form 57.123 Yearly Maintenance (form not used)	Form	New	Available
Form 57.123 AUR Microbiolgy Data Electronic Upload Specification Tables (Yearly Maintenance)	Form	New	Available
Form 57.123 Initial Set-up (form not used)	Form	New	Available
Form 57.123 AUR Microbiology Data Electronic Upload Specification Tables (Initial Set-up)	Form	New	Repair queued
Form 57.102 NHSN Help Desk Customer Satisfaction Survey	Form and Instruction	New	Available
Form 57.102 NHSN Help Desk Customer Satisfaction Survey	Form and Instruction	New	Repair queued
Form CDC 57.302 Hemovigilance Module Monthly Incident Summary	Form and Instruction	Modified	Available
Form CDC 57.302 Hemovigilance Module Monthly Incident Summary	Form and Instruction	Modified	Repair queued
Form 57.800 Billing Code Data	Form	Modified	Available
Form 57.800 Billing Code Data: 837I Upload	Form	Modified	Repair queued
Form 57.701 Glycemic Control Module-HYPO Annual Survey	Form and Instruction	Modified	Available
Form 57.701 57.701 - Glycemic Control Module-HYPO Annual Survey	Form and Instruction	Modified	Repair queued
Form 57.700 Reporting Plan Glycemic Control Module Hypoglycemia	Form and Instruction	Modified	Available
Form 57.700 57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist	Form and Instruction	Modified	Repair queued
Form 57.700 Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE) -IT Yearly Maintenance	Form and Instruction	Modified	Available
Form 57.700 57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance	Form and Instruction	Modified	Repair queued
Form 57.700 Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE) -IT Initial Set up	Form and Instruction	Modified	Available
Form 57.700 57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Initial Set up	Form and Instruction	Modified	Repair queued
Form 57.600 Reporting Plan LOSMEN	Form and Instruction	Modified	Available
Form 57.600 57.600 - Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist	Form and Instruction	Modified	Repair queued
Form 57.600 Reporting Plan LOSMEN	Form and Instruction	Modified	Available
Form 57.600 57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist	Form and Instruction	Modified	Repair queued
Form 57.600 Reporting Plan LOSMEN Yearly Maintenance	Form and Instruction	Modified	Available
Form 57.600 57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance	Form and Instruction	Modified	Repair queued
Form 57.600 Reporting Plan LOSMEN Initial Set-up	Form and Instruction	Modified	Available
Form 57.600 57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up	Form and Instruction	Modified	Repair queued
Form 57.145 LTC-AU Module	Form and Instruction	Modified	Available
Form 57.145 57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA	Form and Instruction	Modified	Available
Form 57.144 Long-Term Care RTI Module	Form and Instruction	Removed	Available
Form 57.144 57.144 - Long Term Care Respiratory Tract Infections (RTI) Module	Form and Instruction	Removed	Repair queued
Form 57.133 Reporting Plan Venous Thromboembolism	Form and Instruction	Removed	Available
Form 57.133 57.133 - Patient Safety Component FHIR Measures-VTE Module- Infection Preventionist	Form and Instruction	Removed	Repair queued
Form 57.133 Reporting Plan Venous Thromboembolism	Form and Instruction	Removed	Available
Form 57.133 57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Yearly Maintenance	Form and Instruction	Removed	Repair queued
Form 57.133 Reporting Plan Venous Thromboembolism	Form and Instruction	Removed	Available
Form 57.133 57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Initial Set up	Form and Instruction	Removed	Repair queued
Form 57.132 Reporting Plan HOB and HTCDI	Form and Instruction	Modified	Available
Form 57.132 57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist	Form and Instruction	Modified	Repair queued
Form 57.132 Patient Safety Digital Reporting Plan (RPS CSV)	Form and Instruction	Modified	Available
Form 57.132 57.132 - Patient Safety Digital Reporting Plan (RPS CSV)	Form and Instruction	Modified	Repair queued
Form 57.130 Reporting Plan - Respiratory Pathogens Surveillance (RPS)	Form and Instruction	Removed	Available
Form 57.130 57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS)-Infection Preventionist	Form and Instruction	Removed	Available
Form 57.130 Reporting Plan - Respiratory Pathogens Surveillance (RPS)	Form and Instruction	Removed	Available
Form 57.130 57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Yearly Maintenance	Form and Instruction	Removed	Available
Form 57.130 Reporting Plan - Respiratory Pathogens Surveillance (RPS)	Form and Instruction	Removed	Available
Form 57.130 57.130 Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Initial Set up	Form and Instruction	Removed	Repair queued
Form 57.408 Monthly Survey Patient Days & Nurse Staffing	Form and Instruction	Modified	Available
Form 57.408 Monthly Survey Patient Days & Nurse Staffing	Form and Instruction	Modified	Repair queued
Form CDC 57.214 Annual Healthcare Personnel Influenza Vaccination Summary	Form and Instruction	Modified	Available
Form CDC 57.214 Annual Healthcare Personnel Influenza Vaccination Summary (manual)	Form and Instruction	Modified	Repair queued
Form 0920-0666 Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Removed	Available
Form 0920-0666 Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Removed	Repair queued
Form 0920-0666 Weekly HCP Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Removed	Available
Form 0920-0666 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Removed	Available
Form CDC 57.211 Weekly HCP Influenza Vaccination Cumulative Summary Non-Long-Term Care Facilities	Form and Instruction	Modified	Available
Form CDC 57.211 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities	Form and Instruction	Modified	Repair queued
Form 57.601 Late Onset Sepsis/ Meningitis Denominator Form: Data Table for monthly electronic upload	Form and Instruction	Modified	Available
Form 57.601 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly)	Form and Instruction	Modified	Repair queued
Form 57.602 Long-Term Care Facility Component – Respiratory Tract Infection	Form and Instruction	Modified	Available
Form 57.602 Long Term Care Facility Component - Respiratory Tract Infection	Form and Instruction	Modified	Repair queued
Facility Administrator Change Request	Form and Instruction	Modified	Available
57.104 NHSN Administrator Change Request Form	Form and Instruction	Modified	Repair queued
Form CDC 55.122 State Health Department HAI Mandate and Validatyion Survey	Form	Modified	Available
Form CDC 55.122 57.122 HAI Progress Report State Health Department Survey	Form	Modified	Available
Form CDC 57.405 Outpatient Procedure Component - SSI Denominators	Form	Modified	Available
Form CDC 57.405 57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event	Form	Modified	Repair queued
Form 57.404 Outpatient Procedure Component - SSI Denominators	Form	Modified	Available
Form 57.404 57.404 Outpatient Procedure Component - SSI Denominators	Form	Modified	Repair queued
Form 57.507 Home Dialysis Center Practices Survey	Form	Modified	Available
Form 57.507 57.507 Home Dialysis Center Practices Survey	Form	Modified	Repair queued
Form 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	Form	Modified	Available
Form 57.320 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	Form	Modified	Available
Form CDC 57.319 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	Form	Modified	Available
Form CDC 57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	Form	Modified	Available
Form CDC 57.318 57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	Form	Modified	Repair queued
Form 57.317 Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury	Form	Modified	Available
Form 57.317 57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury	Form	Modified	Repair queued
Form CDC 57.316 Hemovigilance Adverse Reaction - Transfusin Associated Graft vs. Host Disease	Form	Modified	Available
Form CDC 57.316 57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease	Form	Modified	Repair queued
Form CDC 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	Form	Modified	Available
Form CDC 57.315 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	Form	Modified	Repair queued
Form 57.314 Hwemovilgilance Adverse Reaction - Post Transfusion Purpura	Form	Modified	Available
Form 57.314 57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura	Form	Modified	Repair queued
Form 57.313 Hemovigilance Adverse Reaction - Infection	Form	Modified	Available
Form 57.313 57.313 Hemovigilance Adverse Reaction - Infection	Form	Modified	Repair queued
Form 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	Form	Modified	Available
Form 57.312 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	Form	Modified	Repair queued
Form CDC 57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	Form	Modified	Available
Form CDC 57.311 57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	Form	Modified	Repair queued
Form 57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	Form	Modified	Available
Form 57.310 57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	Form	Modified	Available
Form CDC 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Form	Modified	Available
Form CDC 57.309 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Form	Modified	Repair queued
Form 57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	Form	Modified	Available
Form 57.308 57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	Form	Modified	Repair queued
Form 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	Form	Modified	Available
Form 57.307 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	Form	Modified	Repair queued
Form 57.306 Hemovigilance Module Annual Survey - Non-acute Care Facility	Form	Modified	Available
Form 57.306 57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility	Form	Modified	Repair queued
Form 57.129 Adult Sepsis_	Form	Modified	Available
Form 57.129 57.129_Adult Sepsis	Form	Modified	Repair queued
Form CDC 57.115 Custom Event	Form	Modified	Available
Form CDC 57.115 57.115 Custom Event	Form	Modified	Repair queued
Form 57.113 Pediatric Ventilator-Associated Event (PedVAE)	Form and Instruction	Modified	Available
Form 57.113 57.113 Pediatric Ventilator-Associated Event (PedVAE)	Form and Instruction	Modified	Repair queued
Form CDC 57.506 Dialysis Patient Influenza Vaccination Denominator	Form	Removed	Available
Form CDC 57.506 57.506 Dialysis Patient Influenza Vaccination Denominator	Form	Removed	Repair queued
Form CDC 57.505 Dialysis Patient Influenza Vaccination	Form	Removed	Available
Form CDC 57.505 57.505 Dialysis Patient Influenza Vaccination	Form	Removed	Repair queued
Form CDC 57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Modified	Available
Form CDC 57.504 57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Modified	Available
Form CDC 57.501 NHSN Registration Form	Form	Modified	Available
Form CDC 57.501 57.501 Dialysis Monthly Reporting Plan	Form	Modified	Repair queued
Form CDC 57.403 Outpatient Procedure - Monthly Denominators and Summary	Form	Modified	Available
Form CDC 57.403 57.403 Outpatient Procedure Component - Monthly Denominators and Summary	Form	Modified	Repair queued
Form CDC 57.402 Outpatient Procedure - Component Event	Form	Modified	Available
Form CDC 57.402 57.402 Outpatient Procedure Component Event	Form	Modified	Repair queued
Form CDC 57.401 Outpatient Procedure Component - Monthly Reporting Plan	Form	Modified	Available
Form CDC 57.401 57.401 Outpatient Procedure - Monthly Reporting Plan	Form	Modified	Available
Form CDC 57.400 Outpatient Procedure Component - Annual Facility Survey	Form	Modified	Available
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey	Form	Modified	Repair queued
Form 57.151 Patient Safety Component—Annual Facility Survey for IRF	Form and Instruction	Modified	Available
Form 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF	Form and Instruction	Modified	Repair queued
Form 57.150 Urinary Tract Infection (UTI) for LTCF	Form and Instruction	Modified	Available
Form 57.150 57.150 Patient Safety Component -- Annual Facility Survey for LTAC	Form and Instruction	Modified	Repair queued
Form CDC 57.143 Prevention Process Measures Monthly Monitoring	Form	Modified	Available
Form CDC 57.143 57.143 Prevention Process Measures Monthly Monitoring for LTCF	Form	Modified	Repair queued
Form CDC 57.142 Denominators for LTCF	Form	Modified	Available
Form CDC 57.142 57.142 Denominators for LTCF Locations	Form	Modified	Repair queued
Form CDC 57.141 Monthly Reporting Plan for LTCF	Form	Modified	Available
Form CDC 57.141 57.141 Monthly Reporting Plan for LTCF	Form	Modified	Repair queued
Form 57.112 Ventilator Associated Event (VAE)	Form and Instruction	Modified	Available
Form 57.112 57.112 Ventilator-Associated Event (VAE)	Form and Instruction	Modified	Repair queued
Form CDC 57.139 MDRO and CDI LabID Event Reporting Monthly Summary Data for LTCF	Form	Modified	Available
Form CDC 57.139 57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF	Form	Modified	Repair queued
Form CDC 57.138 Laboratory-identified MDRO or CDI Event for LTCF	Form	Modified	Available
Form CDC 57.138 57.138 Laboratory-Identified MDRO or CDI Event for LTCF	Form	Modified	Repair queued
Form CDC 57.137 Long-Term Care Facility Component -- Annual Facility Survey	Form	Modified	Available
Form CDC 57.137 57.137 Long Term care Facility Component--Annual Facility Survey	Form	Modified	Repair queued
Form CDC 57.305 Hemovigilance Module Incident	Form	Modified	Available
Form CDC 57.305 57.305 Hemovigilance Incident	Form	Modified	Repair queued
Form CDC 57.303 Hemovigilance Module Monthly Reporting Denominators	Form and Instruction	Modified	Available
Form CDC 57.303 57.303 Hemovigilance Module Monthly Reporting Denominators	Form and Instruction	Modified	Repair queued
Form 57.301 Hemovigilance Module Monthly Reporting Plan	Form and Instruction	Modified	Available
Form 57.301 57.301 Hemovigilance Module Monthly Reporting Plan	Form and Instruction	Modified	Repair queued
Form CDC 57.300 Hemovigilance Module - Annual Survey	Form	Modified	Available
Form CDC 57.300 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility	Form	Modified	Repair queued
Form CDC 57.200 Healthcare Personnel Safety - Annual Facility Survey	Form	Removed	Available
Form CDC 57.200 57.200 Healthcare Personnel Safety Component Facility Survey	Form	Removed	Available
Form CDC 57.204 Healthcare Worker Demographic Data	Form	Removed	Available
Form CDC 57.204 57.204 Healthcare Worker Demographic Data	Form	Removed	Repair queued
Form CDC 57.206 Healthcare Worker Prophylaxis/Treatment	Form	Removed	Available
Form CDC 57.206 57.206 Healthcare Worker Prophylaxis/Treatment	Form	Removed	Repair queued
Form CDC 57.205 Exposure to Blood/Body Fluids	Form	Removed	Available
Form CDC 57.205 57.205 Exposure to Blood and Body Fluids	Form	Removed	Repair queued
Form CDC 57.105 Group Contact Information	Form	Modified	Available
Form CDC 57.105 57.105 Group Contact Information	Form	Modified	Repair queued
Form 57.140 Urinary Tract Infection (UTI) for LTCF	Form and Instruction	Modified	Available
Form 57.140 57.140 Urinary Tract Infection (UTI) for LTCF	Form and Instruction	Modified	Repair queued
Form 57.103 Patient Safety Component-Annual Hospital Survey	Form and Instruction	Modified	Available
Form 57.103 57.103 Patient Safety Component - Annual Hospital Survey	Form and Instruction	Modified	Repair queued
Form CDC 57.101 Facility Contact Information	Form	Modified	Available
Form CDC 57.101 57.101 Facility Contact Information	Form	Modified	Available
Form 57.124 Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables	Form and Instruction	Modified	Available
Form 57.124 57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	Form and Instruction	Modified	Repair queued
Form 57.123 Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables	Form and Instruction	Modified	Available
Form 57.123 57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables	Form and Instruction	Modified	Repair queued
Form CDC 57.100 NHSN Registration Form	Form	Modified	Available
Form CDC 57.100 57.100 NHSN Registration Form	Form	Modified	Repair queued
Form 57.121 Denominator for Procedure	Form and Instruction	Modified	Available
Form 57.121 57.121 Denominators for Procedure	Form and Instruction	Modified	Repair queued
Form 57.128 Laboratory-identified MDRO or CDI Event	Form	Modified	Available
Form 57.128 57.128 Laboratory Identified or CDI MDRO Event	Form	Modified	Repair queued
Form CDC 57.120 Surgical Site Infection	Form	Modified	Available
Form CDC 57.120 57.120 Surgical Site Infection (SSI)	Form	Modified	Repair queued
Form CDC 57.126 MDRO or CDI Infection Event	Form	Modified	Available
Form CDC 57.126 57.126 MDRO or CDI Infection Event	Form	Modified	Repair queued
Form CDC 57.503 Demominators for Dialysis Event Surveillance	Form	Modified	Available
Form CDC 57.503 57.503 Denominators for Outpatient Dialysis	Form	Modified	Repair queued
Form CDC 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting	Form	Modified	Available
Form CDC 57.127 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	Form	Modified	Available
Form CDC 57.118 Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)	Form	Modified	Available
Form CDC 57.118 57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)	Form	Modified	Repair queued
Form CDC 57.207 Follow-up Laboratory Testing	Form	Removed	Available
Form CDC 57.207 57.207 Follow-up Laboratory Testing	Form	Removed	Repair queued
Form CDC 57.117 Denominators for Specialty Care Area (SCA)/Oncology (ONC)	Form	Modified	Available
Form CDC 57.117 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)	Form	Modified	Repair queued
Form CDC 57.125 Central Line Insertion Practices Adherence Monitoring	Form	Modified	Available
Form CDC 57.125 57.125 Central Line Insertion Practices Adherence Monitoring Form	Form	Modified	Available
Form CDC 57.116 PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)	Form	Modified	Available
Form CDC 57.116 57.116 Denominators for Neonatal Intensive Care Unit (NICU)	Form	Modified	Repair queued
Form 57.114 Urinary Tract infection (UTI)	Form and Instruction	Modified	Available
Form 57.114 57.114 Urinary Tract Infection (UTI)	Form and Instruction	Modified	Repair queued
Form CDC 57.210 HCW Prophylaxis/Treatment-Influenza	Form	Removed	Available
Form CDC 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Form	Removed	Repair queued
Form 57.111 Pneumonia (PNEU)	Form and Instruction	Modified	Available
Form 57.111 57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	Form and Instruction	Modified	Available
Form CDC 57.502 Dialysis Event	Form and Instruction	Modified	Available
Form CDC 57.502 57.502 Dialysis Event	Form and Instruction	Modified	Repair queued
Form 57.108 Primary Bloodstream Infection (BSI)	Form and Instruction	Modified	Available
Form 57.108 57.108 Primary Bloodstream Infection (BSI)	Form and Instruction	Modified	Repair queued
Form 57.500 Home Dialysis Center Practices Survey	Form and Instruction	Modified	Available
Form 57.500 57.500 Outpatient Dialysis Center Practices Survey	Form and Instruction	Modified	Repair queued
Form CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan	Form	Removed	Available
Form CDC 57.203 57.203 Healthcare Personnel Safety Reporting Plan	Form	Removed	Repair queued
B3. Response to Comment#2.pdf	Public Comments	Uploaded 2024-11-14	Repair queued
B2. Comment #2_v2.pdf	Public Comments	Uploaded 2024-06-24	Repair queued
B1. Comment #1.pdf	Public Comments	Uploaded 2024-06-24	Repair queued
2025 OMB FHIR RPS Data Dictionary_Updated_8_23_2024.xlsx	Supplementary Document	Uploaded 2024-10-31	Available
2025 OMB FHIR RPS Data Dictionary_Updated_8_23_2024.xlsx	Supplementary Document	Uploaded 2024-10-31	Repair queued
2025 OMB FHIR ACH Monthly Measures Data Dictionary_8_23_2024.xlsx	Supplementary Document	Uploaded 2024-10-31	Available
2025 OMB FHIR ACH Monthly Measures Data Dictionary_8_23_2024.xlsx	Supplementary Document	Uploaded 2024-10-31	Repair queued
G3. Privacy Impact Assessment_NHSN_PIA_Signed_2023-01-19.pdf	Supplementary Document	Uploaded 2024-10-31	Repair queued
G3. Privacy Impact Assessment_NHSN_PIA_Signed_2023-01-19.pdf	Supplementary Document	Uploaded 2024-10-31	Repair queued
G2. Privacy Impact Assessment_ NHSN2-Cloud_PIA_Signed_2023-12-05_eRAP.pdf	Supplementary Document	Uploaded 2024-10-31	Available
G2. Privacy Impact Assessment_ NHSN2-Cloud_PIA_Signed_2023-12-05_eRAP.pdf	Supplementary Document	Uploaded 2024-10-31	Repair queued
G1. Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2024-10-31	Repair queued
G1. Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2024-10-31	Repair queued
F2. NHSN 308d Request for Extension and Ammendment.docx	Supplementary Document	Uploaded 2024-10-31	Repair queued
F2. NHSN 308d Request for Extension and Ammendment.docx	Supplementary Document	Uploaded 2024-10-31	Repair queued
F1. NHSN 308d Approval 2015.pdf	Supplementary Document	Uploaded 2024-10-31	Repair queued
F1. NHSN 308d Approval 2015.pdf	Supplementary Document	Uploaded 2024-10-31	Repair queued
E3. Human Subjects Determination_2.pdf	Supplementary Document	Uploaded 2024-10-31	Available
E3. Human Subjects Determination_2.pdf	Supplementary Document	Uploaded 2024-10-31	Repair queued
E2. Report of End of Human Research Review 0.1253.docx	Supplementary Document	Uploaded 2024-10-31	Available
E2. Report of End of Human Research Review 0.1253.docx	Supplementary Document	Uploaded 2024-10-31	Available
E1. Closure CDC Protocol # 4062.docx	Supplementary Document	Uploaded 2024-10-31	Available
E1. Closure CDC Protocol # 4062.docx	Supplementary Document	Uploaded 2024-10-31	Repair queued
D2. Explanation for Program Changes or Adjustments 2024-0920-0666.docx	Supplementary Document	Uploaded 2024-10-31	Available
D2. Explanation for Program Changes or Adjustments 2024-0920-0666.docx	Supplementary Document	Uploaded 2024-10-31	Repair queued
D1. Explanation for Program Changes or Adjustments 2024-0920-0666_v2.docx	Supplementary Document	Uploaded 2024-10-31	Available
D1. Explanation for Program Changes or Adjustments 2024-0920-0666_v2.docx	Supplementary Document	Uploaded 2024-10-31	Repair queued
B. 60-Day Published Federal Register Notice.pdf	Supplementary Document	Uploaded 2024-10-30	Available
B. 60-Day Published Federal Register Notice.pdf	Supplementary Document	Uploaded 2024-10-30	Repair queued
A3. 42 USC 242m.pdf	Supplementary Document	Uploaded 2024-10-30	Repair queued
A3. 42 USC 242m.pdf	Supplementary Document	Uploaded 2024-10-30	Repair queued
A2. 42 USC 242k.pdf	Supplementary Document	Uploaded 2024-10-30	Available
A2. 42 USC 242k.pdf	Supplementary Document	Uploaded 2024-10-30	Repair queued
A1. 42 USC 242b.pdf	Supplementary Document	Uploaded 2024-10-30	Available
A1. 42 USC 242b.pdf	Supplementary Document	Uploaded 2024-10-30	Repair queued
SSB 0920-0666 September 2024.docx	Supporting Statement B	Uploaded 2024-10-30	Available
SSB 0920-0666 September 2024.docx	Supporting Statement B	Uploaded 2024-10-30	Available
SSA 0920-0666 September 2024_FINAL_final_OIRA 12.13.24_clean.docx	Supporting Statement A	Uploaded 2024-12-19	Repair queued
SSA 0920-0666 September 2024_FINAL_final.docx	Supporting Statement A	Uploaded 2024-11-14	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7134	57.106 Patient Safety Monthly Reporting Plan	Form and Instruction	Modified	Patient Safety Monthly Reporting Plan
7134	57.106 Patient Safety Monthly Reporting Plan	Form and Instruction	Modified
272124	All Hazards	Form and Instruction	New	All Hazards
272124	All Hazards	Form and Instruction	New
272123	Bed Capacity-IT Initial Set Up	Form and Instruction	New	Bed Capacity-IT Initial Set Up
272123	Bed Capacity-IT Initial Set Up	Form and Instruction	New
272122	External Validation Summary Report	Form and Instruction	New	External Validation Summary Report
272122	External Validation Summary Report	Form and Instruction	New
272108	Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel	Form and Instruction	New	Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel
272108	Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel	Form and Instruction	New
272105	Annual Healthcare Personnel Influenza Vaccination Summary (CSV)	Form	New	CSV Submission
272105	Annual Healthcare Personnel Influenza Vaccination Summary (CSV)	Form	New
272101	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities (CSV)	Form	New	CSV Submission
272101	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities (CSV)	Form	New
272031	Patient Safety Attestation	Form and Instruction	New	Patient Safety Attestation
272031	Patient Safety Attestation	Form and Instruction	New
272029	Pathogens of High Consequence	Form and Instruction	New	Pathogens of High Consequence
272029	Pathogens of High Consequence	Form and Instruction	New
272027	AUR Pharmacy Data Electronic Upload Specification Tables (Yearly Maintenance)	Form	New	Yearly Maintenance (form not used)
272027	AUR Pharmacy Data Electronic Upload Specification Tables (Yearly Maintenance)	Form	New
272026	AUR Pharmacy Data Electronic Upload Specification Tables (Initial Set-up)	Form	New	Initial Set-up (form not used)
272026	AUR Pharmacy Data Electronic Upload Specification Tables (Initial Set-up)	Form	New
272025	AUR Microbiolgy Data Electronic Upload Specification Tables (Yearly Maintenance)	Form	New	Yearly Maintenance (form not used)
272025	AUR Microbiolgy Data Electronic Upload Specification Tables (Yearly Maintenance)	Form	New
272024	AUR Microbiology Data Electronic Upload Specification Tables (Initial Set-up)	Form	New	Initial Set-up (form not used)
272024	AUR Microbiology Data Electronic Upload Specification Tables (Initial Set-up)	Form	New
272017	NHSN Help Desk Customer Satisfaction Survey	Form and Instruction	New	NHSN Help Desk Customer Satisfaction Survey
272017	NHSN Help Desk Customer Satisfaction Survey	Form and Instruction	New
265665	Hemovigilance Module Monthly Incident Summary	Form and Instruction	Modified	Hemovigilance Module Monthly Incident Summary
265665	Hemovigilance Module Monthly Incident Summary	Form and Instruction	Modified
263469	Billing Code Data: 837I Upload	Form	Modified	Billing Code Data
263469	Billing Code Data: 837I Upload	Form	Modified
263468	57.701 - Glycemic Control Module-HYPO Annual Survey	Form and Instruction	Modified	Glycemic Control Module-HYPO Annual Survey
263468	57.701 - Glycemic Control Module-HYPO Annual Survey	Form and Instruction	Modified
263467	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist	Form and Instruction	Modified	Reporting Plan Glycemic Control Module Hypoglycemia
263467	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist	Form and Instruction	Modified
263466	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance	Form and Instruction	Modified	Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE) -IT Yearly Maintenance
263466	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance	Form and Instruction	Modified
263465	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Initial Set up	Form and Instruction	Modified	Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE) -IT Initial Set up
263465	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Initial Set up	Form and Instruction	Modified
263464	57.600 - Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist	Form and Instruction	Modified	Reporting Plan LOSMEN
263464	57.600 - Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist	Form and Instruction	Modified
263463	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist	Form and Instruction	Modified	Reporting Plan LOSMEN
263463	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist	Form and Instruction	Modified
263462	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance	Form and Instruction	Modified	Reporting Plan LOSMEN Yearly Maintenance
263462	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance	Form and Instruction	Modified
263461	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up	Form and Instruction	Modified	Reporting Plan LOSMEN Initial Set-up
263461	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up	Form and Instruction	Modified
263460	57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA	Form and Instruction	Modified	LTC-AU Module
263460	57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA	Form and Instruction	Modified
263459	57.144 - Long Term Care Respiratory Tract Infections (RTI) Module	Form and Instruction	Removed	Long-Term Care RTI Module
263459	57.144 - Long Term Care Respiratory Tract Infections (RTI) Module	Form and Instruction	Removed
263458	57.133 - Patient Safety Component FHIR Measures-VTE Module- Infection Preventionist	Form and Instruction	Removed	Reporting Plan Venous Thromboembolism
263458	57.133 - Patient Safety Component FHIR Measures-VTE Module- Infection Preventionist	Form and Instruction	Removed
263457	57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Yearly Maintenance	Form and Instruction	Removed	Reporting Plan Venous Thromboembolism
263457	57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Yearly Maintenance	Form and Instruction	Removed
263454	57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Initial Set up	Form and Instruction	Removed	Reporting Plan Venous Thromboembolism
263454	57.133 - Patient Safety Component FHIR Measures-VTE Module-IT Initial Set up	Form and Instruction	Removed
263453	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist	Form and Instruction	Modified	Reporting Plan HOB and HTCDI
263453	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist	Form and Instruction	Modified
263452	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Yearly Maintenance	Other-OMB Header and Burden Statement	Modified
263450	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Initial Set up	Other-OMB Header and Burden Statement	Modified
263449	57.132 - Patient Safety Digital Reporting Plan (RPS CSV)	Form and Instruction	Modified	Patient Safety Digital Reporting Plan (RPS CSV)
263449	57.132 - Patient Safety Digital Reporting Plan (RPS CSV)	Form and Instruction	Modified
263448	57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS)-Infection Preventionist	Form and Instruction	Removed	Reporting Plan - Respiratory Pathogens Surveillance (RPS)
263448	57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS)-Infection Preventionist	Form and Instruction	Removed
263447	57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Yearly Maintenance	Form and Instruction	Removed	Reporting Plan - Respiratory Pathogens Surveillance (RPS)
263447	57.130 - Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Yearly Maintenance	Form and Instruction	Removed
263439	57.130 Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Initial Set up	Form and Instruction	Removed	Reporting Plan - Respiratory Pathogens Surveillance (RPS)
263439	57.130 Patient Safety Component FHIR Measure Respiratory Pathogens Surveillance (RPS) - IT Initial Set up	Form and Instruction	Removed
257463	Monthly Survey Patient Days & Nurse Staffing	Form and Instruction	Modified	Monthly Survey Patient Days & Nurse Staffing
257463	Monthly Survey Patient Days & Nurse Staffing	Form and Instruction	Modified
246758	Annual Healthcare Personnel Influenza Vaccination Summary (manual)	Form and Instruction	Modified	Annual Healthcare Personnel Influenza Vaccination Summary
246758	Annual Healthcare Personnel Influenza Vaccination Summary (manual)	Form and Instruction	Modified
246757	Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Removed	Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities
246757	Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Removed
246756	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Removed	Weekly HCP Influenza Vaccination Cumulative Summary for Long-Term Care Facilities
246756	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Removed
246755	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities	Form and Instruction	Modified	Weekly HCP Influenza Vaccination Cumulative Summary Non-Long-Term Care Facilities
246755	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities	Form and Instruction	Modified
244476	Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly)	Form and Instruction	Modified	Late Onset Sepsis/ Meningitis Denominator Form: Data Table for monthly electronic upload
244476	Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly)	Form and Instruction	Modified
238093	Long Term Care Facility Component - Respiratory Tract Infection	Form and Instruction	Modified	Long-Term Care Facility Component – Respiratory Tract Infection
238093	Long Term Care Facility Component - Respiratory Tract Infection	Form and Instruction	Modified
237430	57.104 NHSN Administrator Change Request Form	Form and Instruction	Modified	Facility Administrator Change Request
237430	57.104 NHSN Administrator Change Request Form	Form and Instruction	Modified
233214	57.122 HAI Progress Report State Health Department Survey	Form	Modified	State Health Department HAI Mandate and Validatyion Survey
233214	57.122 HAI Progress Report State Health Department Survey	Form	Modified
228154	57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event	Form	Modified	Outpatient Procedure Component - SSI Denominators
228154	57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event	Form	Modified
228153	57.404 Outpatient Procedure Component - SSI Denominators	Form	Modified	Outpatient Procedure Component - SSI Denominators
228153	57.404 Outpatient Procedure Component - SSI Denominators	Form	Modified
222908	57.507 Home Dialysis Center Practices Survey	Form	Modified	Home Dialysis Center Practices Survey
222908	57.507 Home Dialysis Center Practices Survey	Form	Modified
222907	57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Other Transfusion Reaction
222907	57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	Form	Modified
222906	57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Unknown Transfusion Reaction
222906	57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	Form	Modified
222905	57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	Form	Modified	Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload
222905	57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	Form	Modified
222904	57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury	Form	Modified	Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury
222904	57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury	Form	Modified
222903	57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease	Form	Modified	Hemovigilance Adverse Reaction - Transfusin Associated Graft vs. Host Disease
222903	57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease	Form	Modified
222902	57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	Form	Modified	Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea
222902	57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	Form	Modified
222901	57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura	Form	Modified	Hwemovilgilance Adverse Reaction - Post Transfusion Purpura
222901	57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura	Form	Modified
222900	57.313 Hemovigilance Adverse Reaction - Infection	Form	Modified	Hemovigilance Adverse Reaction - Infection
222900	57.313 Hemovigilance Adverse Reaction - Infection	Form	Modified
222899	57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction
222899	57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	Form	Modified
222898	57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction
222898	57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	Form	Modified
222897	57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction
222897	57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	Form	Modified
222896	57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction
222896	57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Form	Modified
222895	57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Allergic Transfusion Reaction
222895	57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	Form	Modified
222894	57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	Form	Modified	Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction
222894	57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	Form	Modified
222893	57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility	Form	Modified	Hemovigilance Module Annual Survey - Non-acute Care Facility
222893	57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility	Form	Modified
222892	57.129_Adult Sepsis	Form	Modified	Adult Sepsis_
222892	57.129_Adult Sepsis	Form	Modified
222891	57.115 Custom Event	Form	Modified	Custom Event
222891	57.115 Custom Event	Form	Modified
222890	57.113 Pediatric Ventilator-Associated Event (PedVAE)	Form and Instruction	Modified	Pediatric Ventilator-Associated Event (PedVAE)
222890	57.113 Pediatric Ventilator-Associated Event (PedVAE)	Form and Instruction	Modified
208411	57.506 Dialysis Patient Influenza Vaccination Denominator	Form	Removed	Dialysis Patient Influenza Vaccination Denominator
208411	57.506 Dialysis Patient Influenza Vaccination Denominator	Form	Removed
208410	57.505 Dialysis Patient Influenza Vaccination	Form	Removed	Dialysis Patient Influenza Vaccination
208410	57.505 Dialysis Patient Influenza Vaccination	Form	Removed
208409	57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Modified	Prevention Process Measures Monthly Monitoring for Dialysis
208409	57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Modified
208408	57.501 Dialysis Monthly Reporting Plan	Form	Modified	NHSN Registration Form
208408	57.501 Dialysis Monthly Reporting Plan	Form	Modified
208407	57.403 Outpatient Procedure Component - Monthly Denominators and Summary	Form	Modified	Outpatient Procedure - Monthly Denominators and Summary
208407	57.403 Outpatient Procedure Component - Monthly Denominators and Summary	Form	Modified
208406	57.402 Outpatient Procedure Component Event	Form	Modified	Outpatient Procedure - Component Event
208406	57.402 Outpatient Procedure Component Event	Form	Modified
208405	57.401 Outpatient Procedure - Monthly Reporting Plan	Form	Modified	Outpatient Procedure Component - Monthly Reporting Plan
208405	57.401 Outpatient Procedure - Monthly Reporting Plan	Form	Modified
208404	57.400 Outpatient Procedure - Annual Facility Survey	Form	Modified	Outpatient Procedure Component - Annual Facility Survey
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	Patient Safety Component—Annual Facility Survey for IRF
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	Urinary Tract Infection (UTI) for LTCF
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	Prevention Process Measures Monthly Monitoring
200380	57.143 Prevention Process Measures Monthly Monitoring for LTCF	Form	Modified
200379	57.142 Denominators for LTCF Locations	Form	Modified	Denominators for LTCF
200379	57.142 Denominators for LTCF Locations	Form	Modified
200378	57.141 Monthly Reporting Plan for LTCF	Form	Modified	Monthly Reporting Plan for LTCF
200378	57.141 Monthly Reporting Plan for LTCF	Form	Modified
200377	57.112 Ventilator-Associated Event (VAE)	Form and Instruction	Modified	Ventilator Associated Event (VAE)
200377	57.112 Ventilator-Associated Event (VAE)	Form and Instruction	Modified
197543	57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF	Form	Modified	MDRO and CDI LabID Event Reporting Monthly Summary Data for LTCF
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	Laboratory-identified MDRO or CDI Event for LTCF
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	Long-Term Care Facility Component -- Annual Facility Survey
197541	57.137 Long Term care Facility Component--Annual Facility Survey	Form	Modified
190364	57.305 Hemovigilance Incident	Form	Modified	Hemovigilance Module Incident
190364	57.305 Hemovigilance Incident	Form	Modified
190363	57.303 Hemovigilance Module Monthly Reporting Denominators	Form and Instruction	Modified	Hemovigilance Module Monthly Reporting Denominators
190363	57.303 Hemovigilance Module Monthly Reporting Denominators	Form and Instruction	Modified
190361	57.301 Hemovigilance Module Monthly Reporting Plan	Form and Instruction	Modified	Hemovigilance Module Monthly Reporting Plan
190361	57.301 Hemovigilance Module Monthly Reporting Plan	Form and Instruction	Modified
190360	57.300 Hemovigilance Module Annual Survey -- Acute Care Facility	Form	Modified	Hemovigilance Module - Annual Survey
190360	57.300 Hemovigilance Module Annual Survey -- Acute Care Facility	Form	Modified
183582	57.200 Healthcare Personnel Safety Component Facility Survey	Form	Removed	Healthcare Personnel Safety - Annual Facility Survey
183582	57.200 Healthcare Personnel Safety Component Facility Survey	Form	Removed
183579	57.204 Healthcare Worker Demographic Data	Form	Removed	Healthcare Worker Demographic Data
183579	57.204 Healthcare Worker Demographic Data	Form	Removed
183578	57.206 Healthcare Worker Prophylaxis/Treatment	Form	Removed	Healthcare Worker Prophylaxis/Treatment
183578	57.206 Healthcare Worker Prophylaxis/Treatment	Form	Removed
183577	57.205 Exposure to Blood and Body Fluids	Form	Removed	Exposure to Blood/Body Fluids
183577	57.205 Exposure to Blood and Body Fluids	Form	Removed
183576	57.105 Group Contact Information	Form	Modified	Group Contact Information
183576	57.105 Group Contact Information	Form	Modified
183573	57.140 Urinary Tract Infection (UTI) for LTCF	Form and Instruction	Modified	Urinary Tract Infection (UTI) for LTCF
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	Patient Safety Component-Annual Hospital Survey
183572	57.103 Patient Safety Component - Annual Hospital Survey	Form and Instruction	Modified
183570	57.101 Facility Contact Information	Form	Modified	Facility Contact Information
183570	57.101 Facility Contact Information	Form	Modified
183568	57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	Form and Instruction	Modified	Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables
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	Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables
183566	57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables	Form and Instruction	Modified
183565	57.100 NHSN Registration Form	Form	Modified	NHSN Registration Form
183565	57.100 NHSN Registration Form	Form	Modified
183564	57.121 Denominators for Procedure	Form and Instruction	Modified	Denominator for Procedure
183564	57.121 Denominators for Procedure	Form and Instruction	Modified
183563	57.128 Laboratory Identified or CDI MDRO Event	Form	Modified	Laboratory-identified MDRO or CDI Event
183563	57.128 Laboratory Identified or CDI MDRO Event	Form	Modified
183562	57.120 Surgical Site Infection (SSI)	Form	Modified	Surgical Site Infection
183562	57.120 Surgical Site Infection (SSI)	Form	Modified
183561	57.126 MDRO or CDI Infection Event	Form	Modified	MDRO or CDI Infection Event
183561	57.126 MDRO or CDI Infection Event	Form	Modified
183560	57.503 Denominators for Outpatient Dialysis	Form	Modified	Demominators for Dialysis Event Surveillance
183560	57.503 Denominators for Outpatient Dialysis	Form	Modified
183559	57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	Form	Modified	MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting
183559	57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	Form	Modified
183558	57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)	Form	Modified	Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
183558	57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)	Form	Modified
183557	57.207 Follow-up Laboratory Testing	Form	Removed	Follow-up Laboratory Testing
183557	57.207 Follow-up Laboratory Testing	Form	Removed
183556	57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)	Form	Modified	Denominators for Specialty Care Area (SCA)/Oncology (ONC)
183556	57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)	Form	Modified
183555	57.125 Central Line Insertion Practices Adherence Monitoring Form	Form	Modified	Central Line Insertion Practices Adherence Monitoring
183555	57.125 Central Line Insertion Practices Adherence Monitoring Form	Form	Modified
183554	57.116 Denominators for Neonatal Intensive Care Unit (NICU)	Form	Modified	PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)
183554	57.116 Denominators for Neonatal Intensive Care Unit (NICU)	Form	Modified
183551	57.114 Urinary Tract Infection (UTI)	Form and Instruction	Modified	Urinary Tract infection (UTI)
183551	57.114 Urinary Tract Infection (UTI)	Form and Instruction	Modified
183550	57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Form	Removed	HCW Prophylaxis/Treatment-Influenza
183550	57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Form	Removed
183549	57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	Form and Instruction	Modified	Pneumonia (PNEU)
183549	57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	Form and Instruction	Modified
183547	57.502 Dialysis Event	Form and Instruction	Modified	Dialysis Event
183547	57.502 Dialysis Event	Form and Instruction	Modified
183545	57.108 Primary Bloodstream Infection (BSI)	Form and Instruction	Modified	Primary Bloodstream Infection (BSI)
183545	57.108 Primary Bloodstream Infection (BSI)	Form and Instruction	Modified
183544	57.500 Outpatient Dialysis Center Practices Survey	Form and Instruction	Modified	Home Dialysis Center Practices Survey
183544	57.500 Outpatient Dialysis Center Practices Survey	Form and Instruction	Modified
183543	57.203 Healthcare Personnel Safety Reporting Plan	Form	Removed	Healthcare Personnel Safety Monthly Reporting Plan
183543	57.203 Healthcare Personnel Safety Reporting Plan	Form	Removed

ICR Details

OMB Control No: 0920-0666	ICR Reference No: 202410-0920-013
Status: Historical Active	Previous ICR Reference No: 202402-0920-011
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
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/19/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/15/2024
Terms of Clearance: Approved consistent with the understanding that in the next revision/extension of the package, the agency will update this information collect to use detailed race/ethnicity question (SPD 15, Figure 1, March 28, 2024) or the agency will justify in Supporting Statement A why it cannot use the detailed question.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2027	36 Months From Approved	12/31/2026
Responses	5,896,361	0	5,267,622
Time Burden (Hours)	4,397,234	0	2,433,165
Cost Burden (Dollars)	0	0	0

---

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. The proposed changes in this ICR includes revisions made to 74 approved NHSN data collection tools and 10 new forms, for a total of 84 forms in this package.

---

Authorizing Statute(s): US Code: 42 USC 242b Name of Law: Public Health Service Act
   US Code: 42 USC 242k Name of Law: Public Health Service Act
   US Code: 42 USC 242m(d) Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 30367	04/23/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 87582	11/04/2024
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 98

table that charts list of burden

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	Central Line Insertion Practices Adherence Monitoring
57.126 MDRO or CDI Infection Event	CDC 57.126	MDRO or CDI Infection Event
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	57.128	Laboratory-identified MDRO or CDI Event
57.129_Adult Sepsis	57.129	Adult Sepsis_
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 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Yearly Maintenance
57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist	57.132	Reporting Plan HOB and HTCDI
57.132 - Patient Safety Digital Reporting Plan (RPS CSV)	57.132	Patient Safety Digital Reporting Plan (RPS CSV)
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
57.137 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 LabID Event Reporting Monthly Summary Data 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	Hemovigilance Module - Annual Survey
57.301 Hemovigilance Module Monthly Reporting Plan	57.301	Hemovigilance Module Monthly Reporting Plan
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	Hemovigilance Module Annual Survey - Non-acute Care Facility
57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	57.307	Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction
57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	57.308	Hemovigilance Adverse Reaction - Allergic Transfusion Reaction
57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	CDC 57.309	Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction
57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	57.310	Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction
57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	CDC 57.311	Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction
57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	57.312	Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction
57.313 Hemovigilance Adverse Reaction - Infection	57.313	Hemovigilance Adverse Reaction - Infection
57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura	57.314	Hwemovilgilance Adverse Reaction - Post Transfusion Purpura
57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	CDC 57.315	Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea
57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease	CDC 57.316	Hemovigilance Adverse Reaction - Transfusin Associated Graft vs. Host Disease
57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury	57.317	Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury
57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	CDC 57.318	Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload
57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	CDC 57.319	Hemovigilance Adverse Reaction - Unknown Transfusion Reaction
57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	57.320	Hemovigilance Adverse Reaction - Other Transfusion Reaction
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	Home Dialysis Center Practices Survey
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up	57.600	Reporting Plan LOSMEN Initial Set-up
57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance	57.600	Reporting Plan LOSMEN Yearly Maintenance
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	Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE) -IT Initial Set up
57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance	57.700	Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE) -IT Yearly Maintenance
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 Survey
AUR Microbiolgy Data Electronic Upload Specification Tables (Yearly Maintenance)	57.123	Yearly Maintenance (form not used)
AUR Microbiology Data Electronic Upload Specification Tables (Initial Set-up)	57.123	Initial Set-up (form not used)
AUR Pharmacy Data Electronic Upload Specification Tables (Initial Set-up)	57.124	Initial Set-up (form not used)
AUR Pharmacy Data Electronic Upload Specification Tables (Yearly Maintenance)	57.124	Yearly Maintenance (form not used)
All Hazards	57.803	All Hazards
Annual Healthcare Personnel Influenza Vaccination Summary (CSV)	57.214	CSV Submission
Annual Healthcare Personnel Influenza Vaccination Summary (manual)	CDC 57.214	Annual Healthcare Personnel Influenza Vaccination Summary
Bed Capacity-IT Initial Set Up	57.802	Bed Capacity-IT Initial Set Up
Billing Code Data: 837I Upload	57.800	Billing Code Data
External Validation Summary Report	57.801	External Validation Summary Report
Hemovigilance Module Monthly Incident Summary	CDC 57.302	Hemovigilance Module Monthly Incident Summary
Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly)	57.601	Late Onset Sepsis/ Meningitis Denominator Form: Data Table for monthly electronic upload
Long Term Care Facility Component - Respiratory Tract Infection	57.602	Long-Term Care Facility Component – Respiratory Tract Infection
Monthly Survey Patient Days & Nurse Staffing	57.408	Monthly Survey Patient Days & Nurse Staffing
NHSN Help Desk Customer Satisfaction Survey	57.102	NHSN Help Desk Customer Satisfaction Survey
Pathogens of High Consequence	57.130	Pathogens of High Consequence
Patient Safety Attestation	57.133	Patient Safety Attestation
Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel	57.215	Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel
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	CDC 57.211	Weekly HCP Influenza Vaccination Cumulative Summary Non-Long-Term Care Facilities
Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities (CSV)	57.211	CSV Submission
Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities	0920-0666	Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	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	5,896,361	5,267,622	0	665,835	-37,096	0
Annual Time Burden (Hours)	4,397,234	2,433,165	0	2,440,334	-476,265	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: Miscellaneous Actions

Short Statement: The program made changes to 74 forms and added and retired several forms as well.

---

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

---

Common Form ICR:  No

---

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: 11/15/2024

---