57.151 Patient Safety Component -- Annual Facility Survey for IRF

[NCEZID] 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⚠️ Notice: This information collection may be referencing outdated material.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 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form
Form CDC 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form
CDC 57.151 Patient Safety Component - Annual Facility Survey for IR 57.151_REHAB Annual Facility Survey_BLANK 2020_OMB.docx Form
CDC 57.151 Patient Safety Component - Annual Facility Survey for IR 57.151_REHAB Annual Facility Survey_BLANK 2020_OMB.docx Form
57.151 Patient Safety Component—Annual Facility Survey for IRF 57.151_REHAB Annual Facility Survey_2022.docx Form and Instruction
57.151 Patient Safety Component—Annual Facility Survey for IRF 57.151_REHAB Annual Facility Survey_2022.docx Form and Instruction
19. Sepsis.pdf Att G19_Sepsis IC Document
19. Sepsis.pdf Att G19_Sepsis IC Document

Information Collection (IC) Details

IC Title:	57.151 Patient Safety Component -- Annual Facility Survey for IRF	Agency IC Tracking Number:	0920-0666

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 57.151	Patient Safety Component - Annual Facility Survey for IRF	57.151_REHAB Annual Facility Survey_BLANK 2020_OMB.docx		Yes	Yes	Fillable Fileable
Form and Instruction	57.151	Patient Safety Component—Annual Facility Survey for IRF	57.151_REHAB Annual Facility Survey_2022.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,340	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	1,340	1,340
Annual IC Time Burden (Hours)	1,831	1,831
Annual IC Cost Burden (Dollars)	53,144	53,144

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.