2024-25552. Agency Forms Undergoing Paperwork Reduction Act Review

Estimated Annualized Burden Hours

	Form number & name	Number of respondents	Number of responses per respondent	Average burden per response (min./hour 60)
1	57.100 NHSN Registration Form	2,000	1	5/60
2	57.101 Facility Contact Information	2,000	1	10/60
3	57.102 NHSN Help Desk Customer Satisfaction Survey	26,400	1	2/60
4	57.103 Patient Safety Component—Annual Hospital Survey	5,400	1	137/60
5	57.104 NHSN Facility Administrator Change Request Form	800	1	5/60
6	57.105 Group Contact Information	1,000	1	5/60
7	57.106 Patient Safety Monthly Reporting Plan	7,821	12	15/60
8	57.108 Primary Bloodstream Infection (BSI)	6,000	12	42/60
9	57.111 Pneumonia (PNEU)	1,800	2	34/60
10	57.112 Ventilator-Associated Event (VAE)	5,463	8	32/60
11	57.113 Pediatric Ventilator-Associated Event (PedVAE)	334	1	34/60
12	57.114 Urinary Tract Infection (UTI)	6,000	12	24/60
13	57.115 Custom Event	600	91	39/60
14	57.116 Denominators for Neonatal Intensive Care Unit (NICU)	1,100	12	240/60
15	57.117 Denominators for Specialty Care Area (SCA)/Oncology (ONC)	500	12	300/60
16	57.118 Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)	5,500	60	300/60
17	57.120 Surgical Site Infection (SSI)	3,800	12	14/60
18	57.121 Denominator for Procedure	3,800	12	14/60
19	57.122 HAI Progress Report State Health Department Survey	55	1	50/60
20	57.123 Antimicrobial Use and Resistance (AUR)—Microbiology Data Electronic Upload Specification Tables—Initial Set-up	2,200	1	4,800/60
	57.123 Antimicrobial Use and Resistance (AUR)—Microbiology Data Electronic Upload Specification Tables—Yearly Maintenance	3,300	2	120/60
	57.123 Antimicrobial Use and Resistance (AUR)—Microbiology Data Electronic Upload Specification Tables—Monthly	5,500	12	5/60
21	57.124 Antimicrobial Use and Resistance (AUR)—Pharmacy Data Electronic Upload Specification Tables—Initial Set-up	1,500	1	2,400/60
	57.124 Antimicrobial Use and Resistance (AUR)—Pharmacy Data Electronic Upload Specification Tables—Yearly Maintenance	4,000	1	120/60
	57.124 Antimicrobial Use and Resistance (AUR)—Pharmacy Data Electronic Upload Specification Tables—Monthly	5,500	12	5/60
22	57.125 Central Line Insertion Practices Adherence Monitoring	500	213	26/60
23	57.126 MDRO or CDI Infection Form	720	12	34/60
24	57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring	5,500	29	15/60
25	57.128 Laboratory-identified MDRO or CDI Event	4,800	12	24/60
26	57.129 Adult Sepsis	50	12	28/60
27	57.130 Pathogens of High Consequence	3,650	365	30/60
28	57.132 Patient Safety Component Digital Measure Reporting Plan (HOB, HT-CDI, VTE, Adult Sepsis, RPS, NVAP)-IT Initial Set up	5,500	1	1,620/60
	57.132 Patient Safety Component Digital Measure Reporting Plan (HOB, HT-CDI, VTE, Adult Sepsis, RPS, NVAP)-IT Yearly Maintenance	5,500	1	1,200/60
	57.132 Patient Safety Component Digital Measure Reporting Plan (HOB, HT-CDI, VTE, Adult Sepsis, RPS, NVAP)-Infection Preventionist	5,500	4	10/60
	57.132 Patient Safety Digital Reporting Plan (RPS CSV)	5,500	365	2/60
( print page 87584)
29	57.133 Patient Safety Attestation	3,500	1	10/60
30	57.137 Long-Term Care Facility Component—Annual Facility Survey	6,270	1	135/60
31	57.138 Laboratory-identified MDRO or CDI Event for LTCF	286	24	23/60
32	57.139 MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF	738	12	10/60
33	57.140 Urinary Tract Infection (UTI) for LTCF	373	24	38/60
34	57.141 Monthly Reporting Plan for LTCF	546	12	5/60
35	57.142 Denominators for LTCF Locations	724	12	35/60
36	57.143 Prevention Process Measures Monthly Monitoring for LTCF	434	12	5/60
37	57.145 Long Term Care Antimicrobial Use (LTC-AU) Module CDA	16,500	12	5/60
38	57.150 LTAC Annual Survey	395	1	102/60
39	57.151 Rehab Annual Survey	395	1	102/60
40	57.211 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities-Manual	117	12	25/60
	57.211 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities-.CSV	3,080	12	20/60
41	57.214 Annual Healthcare Personnel Influenza Vaccination Summary-Manual	22,000	1	120/60
	57.214 Annual Healthcare Personnel Influenza Vaccination Summary-.CSV	1,920	1	55/60
42	57.215 Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel	15,426	1	45/60
43	57.300 Hemovigilance Module Annual Survey	63	1	86/60
44	57.301 Hemovigilance Module Monthly Reporting Plan	108	12	1/60
45	57.302 Hemovigilance Module Monthly Incident Summary	9	12	30/60
46	57.303 Hemovigilance Module Monthly Reporting Denominators	102	12	70/60
47	57.305 Hemovigilance Incident	13	77	10/60
48	57.306 Hemovigilance Module Annual Survey—Non-acute care facility	20	1	35/60
49	57.307 Hemovigilance Adverse Reaction—Acute Hemolytic Transfusion Reaction	8	2	22/60
50	57.308 Hemovigilance Adverse Reaction—Allergic Transfusion Reaction	50	11	22/60
51	57.309 Hemovigilance Adverse Reaction—Delayed Hemolytic Transfusion Reaction	9	2	20/60
52	57.310 Hemovigilance Adverse Reaction—Delayed Serologic Transfusion Reaction	19	5	20/60
53	57.311 Hemovigilance Adverse Reaction—Febrile Non-hemolytic Transfusion Reaction	85	13	20/60
54	57.312 Hemovigilance Adverse Reaction—Hypotensive Transfusion Reaction	23	3	20/60
55	57.313 Hemovigilance Adverse Reaction—Infection	2	2	20/60
56	57.314 Hemovigilance Adverse Reaction—Post Transfusion Purpura	1	1	20/60
57	57.315 Hemovigilance Adverse Reaction—Transfusion Associated Dyspnea	18	3	20/60
58	57.316 Hemovigilance Adverse Reaction—Transfusion Associated Graft vs. Host Disease	1	1	20/60
59	57.317 Hemovigilance Adverse Reaction—Transfusion Related Acute Lung Injury	1	1	20/60
60	57.318 Hemovigilance Adverse Reaction—Transfusion Associated Circulatory Overload	40	4	21/60
61	57.319 Hemovigilance Adverse Reaction—Unknown Transfusion Reaction	15	3	20/60
62	57.320 Hemovigilance Adverse Reaction—Other Transfusion Reaction	39	3	20/60
63	57.400 Outpatient Procedure Component—Annual Ambulatory Surgery Center Survey	350	1	10/60
64	57.401 Outpatient Procedure Component—Monthly Reporting Plan	350	12	10/60
65	57.402 Outpatient Procedure Component Same Day Outcome Measures	50	1	43/60
66	57.403 Outpatient Procedure Component—Denominators for Same Day Outcome Measures	50	400	20/60
67	57.404 Outpatient Procedure Component—SSI Denominator	300	100	23/60
68	57.405 Outpatient Procedure Component—Surgical Site (SSI) Event	300	36	40/60
69	57.408 Monthly Survey Patient Days & Nurse Staffing	2,500	12	300/60
70	57.500 Outpatient Dialysis Center Practices Survey	6,900	1	150/60
71	57.501 Dialysis Monthly Reporting Plan	7,400	12	5/60
72	57.502 Dialysis Event	7,400	30	50/60
73	57.503 Denominator for Outpatient Dialysis	7,400	12	10/60
74	57.504 Prevention Process Measures Monthly Monitoring for Dialysis	1,730	12	60/60
75	57.507 Home Dialysis Center Practices Survey	550	1	65/60
76	57.600 Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up	5,500	1	1,620/60
	57.600 Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance	5,500	1	1,200/60
	57.600 Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist	5,500	6	6/60
	57.600 Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist	5,500	12	2/60
77	57.601 Late Onset Sepsis/Meningitis Denominator Form: Late Onset Sepsis/Meningitis Denominator Form: Data Table for monthly electronic upload	300	6	5/60
( print page 87585)
78	57.602 Late Onset Sepsis/Meningitis Event Form: Data Table for Monthly Electronic Upload	300	6	6/60
79	57.700 Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE)—IT Initial Set up	5,500	1	1,620/60
	57.700 Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE)—IT Yearly Maintenance	5,500	1	1,200/60
	57.700 Medication Safety-Digital Measure Reporting Plan (HYPO, HAKI, ORAE)—Infection Preventionist	5,500	4	10/60
80	57.701 Glycemic Control Module-HYPO Annual Survey	10	1	180/60
81	57.800 Billing Code Data: 837I Upload	5,500	4	5/60
82	57.801 External Validation Summary Report	20	2	15/60
83	57.802 Bed Capacity-IT Initial Set Up	25	1	20/60
84	57.803 All Hazards	540	365	5/60