57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)

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⚠️ Notice: This information collection may be referencing outdated material.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 57.111 57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Form
CDC 57.111 Pneumonia COVID-19_FieldAddition _57.111_PNEU_BLANK.docx Form
23. Ventilator Associated Pneumonia.pdf Att G20_Ventilator-Associated Pneumonia IC Document
TOI COVID 19_57.111_PNEU Event (1).docx TOI Instructions IC Document

Information Collection (IC) Details

IC Title:	57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)	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	CDC 57.111	Pneumonia	COVID-19_FieldAddition _57.111_PNEU_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: 1,800	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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,600	-50,400	54,000
Annual IC Time Burden (Hours)	1,800	-26,100	27,900
Annual IC Cost Burden (Dollars)	71,388	-999,432	1,070,820

Documents for IC

Title	Document	Date Uploaded
Att G20_Ventilator-Associated Pneumonia	23. Ventilator Associated Pneumonia.pdf	10/10/2019
TOI Instructions	TOI COVID 19_57.111_PNEU Event (1).docx	06/04/2020

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