Att E_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⚠️ Notice: This information collection may be referencing outdated material.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
Form Phase 4_PIF_201412 Att E_Patient Information Form (PIF) Form
Phase 4_PIF_201412 Patient Information Form (PIF) Att E - PIF.pdf Form
Att G - AUF and HAIF.pdf Att G_ Antimicrobial Use Form IC Document
Att J - EIP HFA.pdf Att J_EIP Healthcare Facility Assessment IC Document
Att K - AQUA Forms.pdf Att K_Antimicrobial Quality Assessment (AQUA) Form 1 IC Document

Information Collection (IC) Details

IC Title:	Att E_Patient Information Form (PIF)	Agency IC Tracking Number:	0920-0852

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	Phase 4_PIF_20141218	Patient Information Form (PIF)	Att E - PIF.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,300	-4,200	10,500
Annual IC Time Burden (Hours)	1,785	-1,190	2,975
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Att G_ Antimicrobial Use Form	Att G - AUF and HAIF.pdf	09/19/2016
Att J_EIP Healthcare Facility Assessment	Att J - EIP HFA.pdf	09/19/2016
Att K_Antimicrobial Quality Assessment (AQUA) Form 1	Att K - AQUA Forms.pdf	09/19/2016

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