57.150 Patient Safety Component -- Annual Facility Survey for LTAC

The National Healthcare Safety Network (NHSN)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form CDC 57.150 57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form
CDC 57.150 Patient Safety Component - Annual Facility Survey for LT 57.150_LTACFacSurv_BLANK.docx Form
19. Sepsis.pdf Att G19_Sepsis IC Document

Information Collection (IC) Details

IC Title:	57.150 Patient Safety Component -- Annual Facility Survey for LTAC	Agency IC Tracking Number:	0920-0666

Is this a Common Form? No		IC Status: Unchanged

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	CDC 57.150	Patient Safety Component - Annual Facility Survey for LTAC	57.150_LTACFacSurv_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	625	625
Annual IC Cost Burden (Dollars)	19,830	19,830

Documents for IC

Title	Document	Date Uploaded
Att G19_Sepsis	19. Sepsis.pdf	09/26/2018

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