57.103 Patient Safety Component - Annual Hospital Survey

[NCEZID] The National Healthcare Safety Network (NHSN)

Documents and Forms

Document Name Document Type
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_2024_CLEAN.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: 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 and Instruction	57.103	Patient Safety Component-Annual Hospital Survey	57.103_ACH Annual Facility Survey_2024_CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,400	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,400	89	5,311
Annual IC Time Burden (Hours)	12,330	380	11,950
Annual IC Cost Burden (Dollars)	0	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.