[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	Unchanged	Available
Form 57.803 All Hazards	Form and Instruction	Unchanged	Available
Form 57.802 Bed Capacity-IT Initial Set Up	Form and Instruction	Unchanged	Available
Form 57.801 External Validation Summary Report	Form and Instruction	Unchanged	Available
Form 57.215 Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel	Form and Instruction	Unchanged	Available
Form 57.214 CSV Submission	Form	Unchanged	Available
Form 57.211 CSV Submission	Form	Unchanged	Available
Form 57.133 Patient Safety Attestation	Form and Instruction	Unchanged	Available
Form 0920-0666 57.130 - Pathogens of High Consequesce [23DEC2024]	Form and Instruction	Modified	Repair queued
Form 57.130 Pathogens of High Consequence	Form and Instruction	Modified	Available
Form 57.124 Yearly Maintenance (form not used)	Form	Unchanged	Available
Form 57.124 Initial Set-up (form not used)	Form	Unchanged	Available
Form 57.123 Yearly Maintenance (form not used)	Form	Unchanged	Available
Form 57.123 Initial Set-up (form not used)	Form	Unchanged	Available
Form 57.102 NHSN Help Desk Customer Satisfaction Survey	Form and Instruction	Unchanged	Available
Form CDC 57.302 Hemovigilance Module Monthly Incident Summary	Form and Instruction	Unchanged	Available
Form 57.800 Billing Code Data	Form	Unchanged	Available
Form 57.701 Glycemic Control Module-HYPO Annual Survey	Form and Instruction	Unchanged	Available
Form 57.700 Reporting Plan Glycemic Control Module Hypoglycemia	Form and Instruction	Unchanged	Available
Form 57.700 Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE) -IT Yearly Maintenance	Form and Instruction	Unchanged	Available
Form 57.700 Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE) -IT Initial Set up	Form and Instruction	Unchanged	Available
Form 57.600 Reporting Plan LOSMEN	Form and Instruction	Unchanged	Available
Form 57.600 Reporting Plan LOSMEN	Form and Instruction	Unchanged	Available
Form 57.600 Reporting Plan LOSMEN Yearly Maintenance	Form and Instruction	Unchanged	Available
Form 57.600 Reporting Plan LOSMEN Initial Set-up	Form and Instruction	Unchanged	Available
Form 57.145 LTC-AU Module	Form and Instruction	Unchanged	Available
Form 57.132 Reporting Plan HOB and HTCDI	Form and Instruction	Unchanged	Available
Form 57.132 Patient Safety Digital Reporting Plan (RPS CSV)	Form and Instruction	Unchanged	Available
Form 57.408 Monthly Survey Patient Days & Nurse Staffing	Form and Instruction	Unchanged	Available
Form CDC 57.214 Annual Healthcare Personnel Influenza Vaccination Summary	Form and Instruction	Unchanged	Available
Form CDC 57.211 Weekly HCP Influenza Vaccination Cumulative Summary Non-Long-Term Care Facilities	Form and Instruction	Unchanged	Available
Form 57.601 Late Onset Sepsis/ Meningitis Denominator Form: Data Table for monthly electronic upload	Form and Instruction	Unchanged	Available
Form 57.602 Long-Term Care Facility Component – Respiratory Tract Infection	Form and Instruction	Unchanged	Available
Facility Administrator Change Request	Form and Instruction	Unchanged	Available
Form CDC 55.122 State Health Department HAI Mandate and Validatyion Survey	Form	Unchanged	Available
Form CDC 57.405 Outpatient Procedure Component - SSI Denominators	Form	Unchanged	Available
Form 57.404 Outpatient Procedure Component - SSI Denominators	Form	Unchanged	Available
Form 57.507 Home Dialysis Center Practices Survey	Form	Unchanged	Available
Form 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	Form	Unchanged	Available
Form CDC 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	Form	Unchanged	Available
Form CDC 57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	Form	Unchanged	Available
Form 57.317 Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury	Form	Unchanged	Available
Form CDC 57.316 Hemovigilance Adverse Reaction - Transfusin Associated Graft vs. Host Disease	Form	Unchanged	Available
Form CDC 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	Form	Unchanged	Available
Form 57.314 Hwemovilgilance Adverse Reaction - Post Transfusion Purpura	Form	Unchanged	Available
Form 57.313 Hemovigilance Adverse Reaction - Infection	Form	Unchanged	Available
Form 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	Form	Unchanged	Available
Form CDC 57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	Form	Unchanged	Available
Form 57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	Form	Unchanged	Available
Form CDC 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Form	Unchanged	Available
Form 57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	Form	Unchanged	Available
Form 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	Form	Unchanged	Repair queued
Form 57.306 Hemovigilance Module Annual Survey - Non-acute Care Facility	Form	Unchanged	Available
Form 57.129 Adult Sepsis_	Form	Unchanged	Available
Form CDC 57.115 Custom Event	Form	Unchanged	Available
Form 57.113 Pediatric Ventilator-Associated Event (PedVAE)	Form and Instruction	Unchanged	Repair queued
Form CDC 57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Unchanged	Available
Form CDC 57.501 NHSN Registration Form	Form	Unchanged	Available
Form CDC 57.403 Outpatient Procedure - Monthly Denominators and Summary	Form	Unchanged	Available
Form CDC 57.402 Outpatient Procedure - Component Event	Form	Unchanged	Available
Form CDC 57.401 Outpatient Procedure Component - Monthly Reporting Plan	Form	Unchanged	Available
Form CDC 57.400 Outpatient Procedure Component - Annual Facility Survey	Form	Unchanged	Available
Form 57.151 Patient Safety Component—Annual Facility Survey for IRF	Form and Instruction	Unchanged	Available
Form 57.150 Urinary Tract Infection (UTI) for LTCF	Form and Instruction	Unchanged	Available
Form CDC 57.143 Prevention Process Measures Monthly Monitoring	Form	Unchanged	Available
Form CDC 57.142 Denominators for LTCF	Form	Unchanged	Available
Form CDC 57.141 Monthly Reporting Plan for LTCF	Form	Unchanged	Available
Form 57.112 Ventilator Associated Event (VAE)	Form and Instruction	Unchanged	Available
Form CDC 57.139 MDRO and CDI LabID Event Reporting Monthly Summary Data for LTCF	Form	Unchanged	Available
Form CDC 57.138 Laboratory-identified MDRO or CDI Event for LTCF	Form	Unchanged	Available
Form CDC 57.137 Long-Term Care Facility Component -- Annual Facility Survey	Form	Unchanged	Available
Form CDC 57.305 Hemovigilance Module Incident	Form	Unchanged	Available
Form CDC 57.303 Hemovigilance Module Monthly Reporting Denominators	Form and Instruction	Unchanged	Available
Form 57.301 Hemovigilance Module Monthly Reporting Plan	Form and Instruction	Unchanged	Available
Form CDC 57.300 Hemovigilance Module - Annual Survey	Form	Unchanged	Available
Form CDC 57.105 Group Contact Information	Form	Unchanged	Available
Form 57.140 Urinary Tract Infection (UTI) for LTCF	Form and Instruction	Unchanged	Available
Form 57.103 Patient Safety Component-Annual Hospital Survey	Form and Instruction	Unchanged	Available
Form CDC 57.101 Facility Contact Information	Form	Unchanged	Available
Form 57.124 Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables	Form and Instruction	Unchanged	Available
Form 57.123 Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables	Form and Instruction	Unchanged	Available
Form CDC 57.100 NHSN Registration Form	Form	Unchanged	Available
Form 57.121 Denominator for Procedure	Form and Instruction	Unchanged	Available
Form 57.128 Laboratory-identified MDRO or CDI Event	Form	Unchanged	Available
Form CDC 57.120 Surgical Site Infection	Form	Unchanged	Available
Form CDC 57.126 MDRO or CDI Infection Event	Form	Unchanged	Available
Form CDC 57.503 Demominators for Dialysis Event Surveillance	Form	Unchanged	Available
Form CDC 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting	Form	Unchanged	Available
Form CDC 57.118 Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)	Form	Unchanged	Available
Form CDC 57.117 Denominators for Specialty Care Area (SCA)/Oncology (ONC)	Form	Unchanged	Available
Form CDC 57.125 Central Line Insertion Practices Adherence Monitoring	Form	Unchanged	Repair queued
Form CDC 57.116 PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)	Form	Unchanged	Available
Form 57.114 Urinary Tract infection (UTI)	Form and Instruction	Unchanged	Available
Form 57.111 Pneumonia (PNEU)	Form and Instruction	Unchanged	Available
Form CDC 57.502 Dialysis Event	Form and Instruction	Unchanged	Available
Form 57.108 Primary Bloodstream Infection (BSI)	Form and Instruction	Unchanged	Available
Form 57.500 Home Dialysis Center Practices Survey	Form and Instruction	Unchanged	Available
Emergency Request Memo_23DEC2024.docx	Supplementary Document	Uploaded 2024-12-23	Available
G3. Privacy Impact Assessment_NHSN_PIA_Signed_2023-01-19.pdf	Supplementary Document	Uploaded 2024-12-23	Repair queued
Human Subject Determination-IRB approval.pdf	Supplementary Document	Uploaded 2024-12-23	Available
2025 OMB FHIR RPS Data Dictionary_Updated_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	Available
G3. Privacy Impact Assessment_NHSN_PIA_Signed_2023-01-19.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	Available
G1. Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2024-10-31	Available
F2. NHSN 308d Request for Extension and Ammendment.docx	Supplementary Document	Uploaded 2024-10-31	Available
F1. NHSN 308d Approval 2015.pdf	Supplementary Document	Uploaded 2024-10-31	Available
E3. Human Subjects Determination_2.pdf	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
D2. Explanation for Program Changes or Adjustments 2024-0920-0666.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	Available
B. 60-Day Published Federal Register Notice.pdf	Supplementary Document	Uploaded 2024-10-30	Available
A3. 42 USC 242m.pdf	Supplementary Document	Uploaded 2024-10-30	Available
A2. 42 USC 242k.pdf	Supplementary Document	Uploaded 2024-10-30	Available
A1. 42 USC 242b.pdf	Supplementary Document	Uploaded 2024-10-30	Available
Supporting Statement B.docx	Supporting Statement B	Uploaded 2024-12-23	Available
Supporting Statement A.docx	Supporting Statement A	Uploaded 2024-12-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7134	57.106 Patient Safety Monthly Reporting Plan	Form and Instruction	Unchanged	Patient Safety Monthly Reporting Plan
272124	All Hazards	Form and Instruction	Unchanged	All Hazards
272123	Bed Capacity-IT Initial Set Up	Form and Instruction	Unchanged	Bed Capacity-IT Initial Set Up
272122	External Validation Summary Report	Form and Instruction	Unchanged	External Validation Summary Report
272108	Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel	Form and Instruction	Unchanged	Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel
272105	Annual Healthcare Personnel Influenza Vaccination Summary (CSV)	Form	Unchanged	CSV Submission
272101	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities (CSV)	Form	Unchanged	CSV Submission
272031	Patient Safety Attestation	Form and Instruction	Unchanged	Patient Safety Attestation
272029	57.130 Pathogens of High Consequence	Form and Instruction	Modified	57.130 - Pathogens of High Consequesce [23DEC2024]
272029	57.130 Pathogens of High Consequence	Form and Instruction	Modified	Pathogens of High Consequence
272027	AUR Pharmacy Data Electronic Upload Specification Tables (Yearly Maintenance)	Form	Unchanged	Yearly Maintenance (form not used)
272026	AUR Pharmacy Data Electronic Upload Specification Tables (Initial Set-up)	Form	Unchanged	Initial Set-up (form not used)
272025	AUR Microbiolgy Data Electronic Upload Specification Tables (Yearly Maintenance)	Form	Unchanged	Yearly Maintenance (form not used)
272024	AUR Microbiology Data Electronic Upload Specification Tables (Initial Set-up)	Form	Unchanged	Initial Set-up (form not used)
272017	NHSN Help Desk Customer Satisfaction Survey	Form and Instruction	Unchanged	NHSN Help Desk Customer Satisfaction Survey
265665	Hemovigilance Module Monthly Incident Summary	Form and Instruction	Unchanged	Hemovigilance Module Monthly Incident Summary
263469	Billing Code Data: 837I Upload	Form	Unchanged	Billing Code Data
263468	57.701 - Glycemic Control Module-HYPO Annual Survey	Form and Instruction	Unchanged	Glycemic Control Module-HYPO Annual Survey
263467	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist	Form and Instruction	Unchanged	Reporting Plan Glycemic Control Module Hypoglycemia
263466	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance	Form and Instruction	Unchanged	Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE) -IT Yearly Maintenance
263465	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Initial Set up	Form and Instruction	Unchanged	Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE) -IT Initial Set up
263464	57.600 - Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist	Form and Instruction	Unchanged	Reporting Plan LOSMEN
263463	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist	Form and Instruction	Unchanged	Reporting Plan LOSMEN
263462	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance	Form and Instruction	Unchanged	Reporting Plan LOSMEN Yearly Maintenance
263461	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up	Form and Instruction	Unchanged	Reporting Plan LOSMEN Initial Set-up
263460	57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA	Form and Instruction	Unchanged	LTC-AU Module
263453	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist	Form and Instruction	Unchanged	Reporting Plan HOB and HTCDI
263452	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Yearly Maintenance	Other-OMB Header and Burden Statement	Unchanged
263450	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Initial Set up	Other-OMB Header and Burden Statement	Unchanged
263449	57.132 - Patient Safety Digital Reporting Plan (RPS CSV)	Form and Instruction	Unchanged	Patient Safety Digital Reporting Plan (RPS CSV)
257463	Monthly Survey Patient Days & Nurse Staffing	Form and Instruction	Unchanged	Monthly Survey Patient Days & Nurse Staffing
246758	Annual Healthcare Personnel Influenza Vaccination Summary (manual)	Form and Instruction	Unchanged	Annual Healthcare Personnel Influenza Vaccination Summary
246755	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities	Form and Instruction	Unchanged	Weekly HCP Influenza Vaccination Cumulative Summary Non-Long-Term Care Facilities
244476	Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly)	Form and Instruction	Unchanged	Late Onset Sepsis/ Meningitis Denominator Form: Data Table for monthly electronic upload
238093	Long Term Care Facility Component - Respiratory Tract Infection	Form and Instruction	Unchanged	Long-Term Care Facility Component – Respiratory Tract Infection
237430	57.104 NHSN Administrator Change Request Form	Form and Instruction	Unchanged	Facility Administrator Change Request
233214	57.122 HAI Progress Report State Health Department Survey	Form	Unchanged	State Health Department HAI Mandate and Validatyion Survey
228154	57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event	Form	Unchanged	Outpatient Procedure Component - SSI Denominators
228153	57.404 Outpatient Procedure Component - SSI Denominators	Form	Unchanged	Outpatient Procedure Component - SSI Denominators
222908	57.507 Home Dialysis Center Practices Survey	Form	Unchanged	Home Dialysis Center Practices Survey
222907	57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction	Form	Unchanged	Hemovigilance Adverse Reaction - Other Transfusion Reaction
222906	57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	Form	Unchanged	Hemovigilance Adverse Reaction - Unknown Transfusion Reaction
222905	57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	Form	Unchanged	Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload
222904	57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury	Form	Unchanged	Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury
222903	57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease	Form	Unchanged	Hemovigilance Adverse Reaction - Transfusin Associated Graft vs. Host Disease
222902	57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	Form	Unchanged	Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea
222901	57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura	Form	Unchanged	Hwemovilgilance Adverse Reaction - Post Transfusion Purpura
222900	57.313 Hemovigilance Adverse Reaction - Infection	Form	Unchanged	Hemovigilance Adverse Reaction - Infection
222899	57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	Form	Unchanged	Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction
222898	57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	Form	Unchanged	Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction
222897	57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	Form	Unchanged	Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction
222896	57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Form	Unchanged	Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction
222895	57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	Form	Unchanged	Hemovigilance Adverse Reaction - Allergic Transfusion Reaction
222894	57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	Form	Unchanged	Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction
222893	57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility	Form	Unchanged	Hemovigilance Module Annual Survey - Non-acute Care Facility
222892	57.129_Adult Sepsis	Form	Unchanged	Adult Sepsis_
222891	57.115 Custom Event	Form	Unchanged	Custom Event
222890	57.113 Pediatric Ventilator-Associated Event (PedVAE)	Form and Instruction	Unchanged	Pediatric Ventilator-Associated Event (PedVAE)
208409	57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form	Unchanged	Prevention Process Measures Monthly Monitoring for Dialysis
208408	57.501 Dialysis Monthly Reporting Plan	Form	Unchanged	NHSN Registration Form
208407	57.403 Outpatient Procedure Component - Monthly Denominators and Summary	Form	Unchanged	Outpatient Procedure - Monthly Denominators and Summary
208406	57.402 Outpatient Procedure Component Event	Form	Unchanged	Outpatient Procedure - Component Event
208405	57.401 Outpatient Procedure - Monthly Reporting Plan	Form	Unchanged	Outpatient Procedure Component - Monthly Reporting Plan
208404	57.400 Outpatient Procedure - Annual Facility Survey	Form	Unchanged	Outpatient Procedure Component - Annual Facility Survey
200382	57.151 Patient Safety Component -- Annual Facility Survey for IRF	Form and Instruction	Unchanged	Patient Safety Component—Annual Facility Survey for IRF
200381	57.150 Patient Safety Component -- Annual Facility Survey for LTAC	Form and Instruction	Unchanged	Urinary Tract Infection (UTI) for LTCF
200380	57.143 Prevention Process Measures Monthly Monitoring for LTCF	Form	Unchanged	Prevention Process Measures Monthly Monitoring
200379	57.142 Denominators for LTCF Locations	Form	Unchanged	Denominators for LTCF
200378	57.141 Monthly Reporting Plan for LTCF	Form	Unchanged	Monthly Reporting Plan for LTCF
200377	57.112 Ventilator-Associated Event (VAE)	Form and Instruction	Unchanged	Ventilator Associated Event (VAE)
197543	57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF	Form	Unchanged	MDRO and CDI LabID Event Reporting Monthly Summary Data for LTCF
197542	57.138 Laboratory-Identified MDRO or CDI Event for LTCF	Form	Unchanged	Laboratory-identified MDRO or CDI Event for LTCF
197541	57.137 Long Term care Facility Component--Annual Facility Survey	Form	Unchanged	Long-Term Care Facility Component -- Annual Facility Survey
190364	57.305 Hemovigilance Incident	Form	Unchanged	Hemovigilance Module Incident
190363	57.303 Hemovigilance Module Monthly Reporting Denominators	Form and Instruction	Unchanged	Hemovigilance Module Monthly Reporting Denominators
190361	57.301 Hemovigilance Module Monthly Reporting Plan	Form and Instruction	Unchanged	Hemovigilance Module Monthly Reporting Plan
190360	57.300 Hemovigilance Module Annual Survey -- Acute Care Facility	Form	Unchanged	Hemovigilance Module - Annual Survey
183576	57.105 Group Contact Information	Form	Unchanged	Group Contact Information
183573	57.140 Urinary Tract Infection (UTI) for LTCF	Form and Instruction	Unchanged	Urinary Tract Infection (UTI) for LTCF
183572	57.103 Patient Safety Component - Annual Hospital Survey	Form and Instruction	Unchanged	Patient Safety Component-Annual Hospital Survey
183570	57.101 Facility Contact Information	Form	Unchanged	Facility Contact Information
183568	57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data	Form and Instruction	Unchanged	Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables
183566	57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables	Form and Instruction	Unchanged	Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables
183565	57.100 NHSN Registration Form	Form	Unchanged	NHSN Registration Form
183564	57.121 Denominators for Procedure	Form and Instruction	Unchanged	Denominator for Procedure
183563	57.128 Laboratory Identified or CDI MDRO Event	Form	Unchanged	Laboratory-identified MDRO or CDI Event
183562	57.120 Surgical Site Infection (SSI)	Form	Unchanged	Surgical Site Infection
183561	57.126 MDRO or CDI Infection Event	Form	Unchanged	MDRO or CDI Infection Event
183560	57.503 Denominators for Outpatient Dialysis	Form	Unchanged	Demominators for Dialysis Event Surveillance
183559	57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	Form	Unchanged	MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting
183558	57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)	Form	Unchanged	Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
183556	57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)	Form	Unchanged	Denominators for Specialty Care Area (SCA)/Oncology (ONC)
183555	57.125 Central Line Insertion Practices Adherence Monitoring Form	Form	Unchanged	Central Line Insertion Practices Adherence Monitoring
183554	57.116 Denominators for Neonatal Intensive Care Unit (NICU)	Form	Unchanged	PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)
183551	57.114 Urinary Tract Infection (UTI)	Form and Instruction	Unchanged	Urinary Tract infection (UTI)
183549	57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	Form and Instruction	Unchanged	Pneumonia (PNEU)
183547	57.502 Dialysis Event	Form and Instruction	Unchanged	Dialysis Event
183545	57.108 Primary Bloodstream Infection (BSI)	Form and Instruction	Unchanged	Primary Bloodstream Infection (BSI)
183544	57.500 Outpatient Dialysis Center Practices Survey	Form and Instruction	Unchanged	Home Dialysis Center Practices Survey

ICR Details

OMB Control No: 0920-0666	ICR Reference No: 202412-0920-019
Status: Historical Active	Previous ICR Reference No: 202410-0920-013
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: Emergency	Approval Requested By: 12/31/2024
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/23/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/23/2024
Terms of Clearance: OMB is approving this Emergency ICR with the understanding that within 5 months from the approval date, CDC will complete a 60d and 30d public comment request to support the approval of the ICR ahead of the expiration date.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2025	5 Months From Approved	12/31/2027
Responses	5,896,361	0	5,896,361
Time Burden (Hours)	4,508,255	0	4,397,234
Cost Burden (Dollars)	0	0	0

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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. This Emergency Revision Request is submitted to add three (3) additional diseases to the data collection, Influenza A (H5), Marburg, and Oropouche. Data will be collected following modification of the previously approved Form 57.130 - Pathogens of High Consequence. An additional 111,021 burden hours will be added to the collection

Emergency Justfication: Emergency Processing is requested to add three (3) additional pathogens of concern to the NHSN (OMB Control No. 0920-0666) data collection: Influenza A (H5), Marburg, and Oropouche. This requested update in disease surveillance will illustrate which patient populations are being affected by these pathogens and the potential need for additional healthcare infection prevention and control. Since this form is collecting data on hospitalized patients, the update will also help inform on the severity of illness a high consequence pathogen is causing as well as what region(s) of the country are affected. Data collection is vital to ensure that local and state authorities are supported to prepare for and respond to emerging outbreaks.

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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

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

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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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 Pathogens of High Consequence	57.130, 0920-0666	Pathogens of High Consequence ,   57.130 - Pathogens of High Consequesce [23DEC2024]
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)
57.137 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
57.145 - 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
57.300 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
57.507 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
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 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

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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	5,896,361	0	0	0	0
Annual Time Burden (Hours)	4,508,255	4,397,234	0	111,021	0	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: No

Burden Reduction Due to:

Short Statement: Emergency Revision Request is submitted for 0920-0666 to add three (3) additional diseases to the existing data (Influenza A (H5), Marburg, and Oropouche). Data will be collected through modification of the previously approved Form 57.130 - Pathogens of High Consequence. An additional 111,021 burden hours will be added to the collection.

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Annual Cost to Federal Government: $49,994,530

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

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Common Form ICR:  No

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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: 12/23/2024

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