Patient Information Form (PIF)

Prevalence Survey of Healthcare Associated Infections (HAIs) and Antimicrobial Use in U.S. Acute Care Hospitals

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0852 can be found here:

Documents and Forms

Document Name Document Type
Patient Information Form (PIF) Form
Patient Information Form AttachmentE_FINAL_0920-0852_PIF_20130618.docx Form

Information Collection (IC) Details

IC Title:	Patient Information Form (PIF)	Agency IC Tracking Number:

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	none	Patient Information Form	AttachmentE_FINAL_0920-0852_PIF_20130618.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	21,000	21,000
Annual IC Time Burden (Hours)	5,950	5,950
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.