[NCEZID] The National Healthcare Safety Network (NHSN)

ICR 202301-0920-005

OMB: 0920-0666

Federal Form Document

⚠️ Notice: This information collection may be outdated.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

Forms and Documents

Document Name	Status
Form 57.106 57.106 Patient Safety Monthly Reporting Plan Form and Instruction	Modified
Monthly Survey Patient Days & Nurse Staffing Form and Instruction	Modified
Form 0920-0666 Annual Healthcare Personnel Influenza Vaccination Summary Form and Instruction	Unchanged
Form 0920-0666 Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	Unchanged
Form 0920-0666 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	Unchanged
Form 0920-0666 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities Form and Instruction	Unchanged
Form 57.135 57.135 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) Form and Instruction	Unchanged
Form 57.136 57.136 Long Term Care Facility Component - Respiratory Tract Infection Form and Instruction	Unchanged
57.104 NHSN Administrator Change Request Form Form and Instruction	Unchanged
Form CDC 55.122 57.122 HAI Progress Report State Health Department Survey Form	Unchanged
Form CDC 57.405 57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Form	Modified
Form 57.404 57.404 Outpatient Procedure Component - SSI Denominators Form	Modified
Form 57.507 57.507 Home Dialysis Center Practices Survey Form	Modified
Form 57.320 57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction Form	Modified
Form CDC 57.319 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction Form	Modified
Form 57.318 57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload Form	Modified
Form 57.317 57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury Form	Modified
Form CDC 57.316 57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease Form	Modified
Form CDC 57.315 57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea Form	Modified
Form 57.314 57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura Form	Modified
Form 57.313 57.313 Hemovigilance Adverse Reaction - Infection Form	Modified
Form 57.312 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction Form	Modified
Form CDC 57.311 57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction Form	Modified
Form 57.310 57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction Form	Modified
Form CDC 57.309 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction Form	Modified
Form 57.308 57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction Form	Modified
Form 57.307 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction Form	Modified
Form 57.306 57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility Form	Modified
Form 57.129 57.129_Adult Sepsis_BLANK Form	Modified
Form CDC 57.115 57.115 Custom Event Form	Modified
Form 57.113 57.113 Pediatric Ventilator-Associated Event (PedVAE) Form and Instruction	Modified
Form CDC 57.506 57.506 Dialysis Patient Influenza Vaccination Denominator Form	Modified
Form CDC 57.505 57.505 Dialysis Patient Influenza Vaccination Form	Modified
Form CDC 57.504 57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form	Modified
Form CDC 57.501 57.501 Dialysis Monthly Reporting Plan Form	Modified
Form CDC 57.403 57.403 Outpatient Procedure Component - Monthly Denominators and Summary Form	Modified
Form CDC 57.402 57.402 Outpatient Procedure Component Event Form	Modified
Form CDC 57.401 57.401 Outpatient Procedure - Monthly Reporting Plan Form	Modified
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey Form	Modified
Form 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form and Instruction	Modified
Form 57.150 57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form and Instruction	Modified
Form CDC 57.143 57.143 Prevention Process Measures Monthly Monitoring for LTCF Form	Modified
Form CDC 57.142 57.142 Denominators for LTCF Locations Form	Modified
Form CDC 57.141 57.141 Monthly Reporting Plan for LTCF Form	Modified
Form 57.112 57.112 Ventilator-Associated Event (VAE) Form and Instruction	Modified
Form CDC 57.139 57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Form	Modified
Form CDC 57.138 57.138 Laboratory-Identified MDRO or CDI Event for LTCF Form	Modified
Form CDC 57.137 57.137 Long Term care Facility Component--Annual Facility Survey Form	Modified
Form CDC 57.305 57.305 Hemovigilance Incident Form	Modified
Form CDC 57.303 57.303 Hemovigilance Module Monthly Reporting Denominators Form	Modified
Form 57.301 57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction	Modified
Form CDC 57.300 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form	Modified
Form CDC 57.200 57.200 Healthcare Personnel Safety Component Facility Survey Form	Modified
Form CDC 57.204 57.204 Healthcare Worker Demographic Data Form	Modified
Form CDC 57.206 57.206 Healthcare Worker Prophylaxis/Treatment Form	Modified
Form CDC 57.205 57.205 Exposure to Blood and Body Fluids Form	Modified
Form CDC 57.105 57.105 Group Contact Information Form	Modified
Form 57.140 57.140 Urinary Tract Infection (UTI) for LTCF Form and Instruction	Modified
57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction	Modified
Form CDC 57.101 57.101 Facility Contact Information Form	Modified
Form 57.124 57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Form and Instruction	Modified
Form 57.123 57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Form and Instruction	Modified
Form CDC 57.100 57.100 NHSN Registration Form Form	Modified
Form 57.121 57.121 Denominators for Procedure Form and Instruction	Modified
Form CDC 57.128 Rev 7, 57.128 Laboratory Identified or CDI MDRO Event Form and Instruction	Modified
Form CDC 57.120 57.120 Surgical Site Infection (SSI) Form	Modified
Form CDC 57.126 57.126 MDRO or CDI Infection Event Form	Modified
Form CDC 57.503 57.503 Denominators for Outpatient Dialysis Form	Modified
Form CDC 57.127 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form	Modified
Form CDC 57.118 57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Form	Modified
Form CDC 57.207 57.207 Follow-up Laboratory Testing Form	Modified
Form CDC 57.117 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form	Modified
Form CDC 57.125 57.125 Central Line Insertion Practices Adherence Monitoring Form Form	Modified
Form CDC 57.116 57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form	Modified
Form 57.114 57.114 Urinary Tract Infection (UTI) Form and Instruction	Modified
Form CDC 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form	Modified
Form 57.111 57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Form and Instruction	Modified
Form CDC 57.502 57.502 Dialysis Event Form and Instruction	Modified
Form 57.108 57.108 Primary Bloodstream Infection (BSI) Form and Instruction	Modified
Form 57.500 57.500 Outpatient Dialysis Center Practices Survey Form and Instruction	Modified
Form CDC 57.203 57.203 Healthcare Personnel Safety Reporting Plan Form	Modified
I. NHSN Change Tracker_04252023.docx Supplementary Document	2023-04-25
H2. Privacy Act Checklist 2022.docx Supplementary Document	2023-01-10
H1. NHSN Signed PIA.pdf Supplementary Document	2023-01-10
G2. NHSN 308d Request for Extension and Ammendment.docx Supplementary Document	2023-01-10
G1. NHSN 308d Approval 2015.pdf Supplementary Document	2023-01-10
F2. Report of End of Human Research Review 0.1253.docx Supplementary Document	2023-01-10
F1. Closure CDC Protocol # 4062.docx Supplementary Document	2023-01-10
E. NHSN Forms used for CMS QRPs State Mandated Reporting.docx Supplementary Document	2023-01-10
D2. Itemized IC Revisions and Justifications.docx Supplementary Document	2023-01-10
D1. 0920-0666 Revision 2022 Explanations and justifications.docx Supplementary Document	2023-01-10
B1. public comment.pdf Supplementary Document	2023-01-10
B. Published 60-day FRN NHSN 2022.pdf Supplementary Document	2023-01-10
A3. 42 USC 242m.pdf Supplementary Document	2023-01-10
A2. 42 USC 242k.pdf Supplementary Document	2023-01-10
A1. 42 USC 242b.pdf Supplementary Document	2023-01-10
SSB_04112023.docx Supporting Statement B	2023-04-25
SSA_04112023.docx Supporting Statement A	2023-04-25

IC Document Collections

IC ID	Document Title	Status
7134	57.106 Patient Safety Monthly Reporting Plan Form and Instruction	Modified
257463	Monthly Survey Patient Days & Nurse Staffing Form and Instruction	Modified
246758	Annual Healthcare Personnel Influenza Vaccination Summary Form and Instruction	Unchanged
246757	Weekly Resident Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	Unchanged
246756	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	Unchanged
246755	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities Form and Instruction	Unchanged
244476	57.135 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) Form and Instruction	Unchanged
238093	57.136 Long Term Care Facility Component - Respiratory Tract Infection Form and Instruction	Unchanged
237430	57.104 NHSN Administrator Change Request Form Form and Instruction	Unchanged
233214	57.122 HAI Progress Report State Health Department Survey Form	Unchanged
228154	57.405 Outpatient Procedure Component - Surgical Site Infection (SSI) Event Form	Modified
228153	57.404 Outpatient Procedure Component - SSI Denominators Form	Modified
222908	57.507 Home Dialysis Center Practices Survey Form	Modified
222907	57.320 Hemovigilance Adverse Reaction - Other Transfusion Reaction Form	Modified
222906	57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction Form	Modified
222905	57.318 Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload Form	Modified
222904	57.317 Hemovigilance Adverse Reaction - Transfusion Associated Acute Lung Injury Form	Modified
222903	57.316 Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease Form	Modified
222902	57.315 Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea Form	Modified
222901	57.314 Hemovigilance Adverse Reaction - Post Transfusion Purpura Form	Modified
222900	57.313 Hemovigilance Adverse Reaction - Infection Form	Modified
222899	57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction Form	Modified
222898	57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction Form	Modified
222897	57.310 Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction Form	Modified
222896	57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction Form	Modified
222895	57.308 Hemovigilance Adverse Reaction - Allergic Transfusion Reaction Form	Modified
222894	57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction Form	Modified
222893	57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility Form	Modified
222892	57.129_Adult Sepsis_BLANK Form	Modified
222891	57.115 Custom Event Form	Modified
222890	57.113 Pediatric Ventilator-Associated Event (PedVAE) Form and Instruction	Modified
208411	57.506 Dialysis Patient Influenza Vaccination Denominator Form	Modified
208410	57.505 Dialysis Patient Influenza Vaccination Form	Modified
208409	57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form	Modified
208408	57.501 Dialysis Monthly Reporting Plan Form	Modified
208407	57.403 Outpatient Procedure Component - Monthly Denominators and Summary Form	Modified
208406	57.402 Outpatient Procedure Component Event Form	Modified
208405	57.401 Outpatient Procedure - Monthly Reporting Plan Form	Modified
208404	57.400 Outpatient Procedure - Annual Facility Survey Form	Modified
200382	57.151 Patient Safety Component -- Annual Facility Survey for IRF Form and Instruction	Modified
200381	57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form and Instruction	Modified
200380	57.143 Prevention Process Measures Monthly Monitoring for LTCF Form	Modified
200379	57.142 Denominators for LTCF Locations Form	Modified
200378	57.141 Monthly Reporting Plan for LTCF Form	Modified
200377	57.112 Ventilator-Associated Event (VAE) Form and Instruction	Modified
197543	57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Form	Modified
197542	57.138 Laboratory-Identified MDRO or CDI Event for LTCF Form	Modified
197541	57.137 Long Term care Facility Component--Annual Facility Survey Form	Modified
190364	57.305 Hemovigilance Incident Form	Modified
190363	57.303 Hemovigilance Module Monthly Reporting Denominators Form	Modified
190361	57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction	Modified
190360	57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form	Modified
183582	57.200 Healthcare Personnel Safety Component Facility Survey Form	Modified
183579	57.204 Healthcare Worker Demographic Data Form	Modified
183578	57.206 Healthcare Worker Prophylaxis/Treatment Form	Modified
183577	57.205 Exposure to Blood and Body Fluids Form	Modified
183576	57.105 Group Contact Information Form	Modified
183573	57.140 Urinary Tract Infection (UTI) for LTCF Form and Instruction	Modified
183572	57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction	Modified
183570	57.101 Facility Contact Information Form	Modified
183568	57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Form and Instruction	Modified
183566	57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Form and Instruction	Modified
183565	57.100 NHSN Registration Form Form	Modified
183564	57.121 Denominators for Procedure Form and Instruction	Modified
183563	57.128 Laboratory Identified or CDI MDRO Event Form and Instruction	Modified
183562	57.120 Surgical Site Infection (SSI) Form	Modified
183561	57.126 MDRO or CDI Infection Event Form	Modified
183560	57.503 Denominators for Outpatient Dialysis Form	Modified
183559	57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form	Modified
183558	57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Form	Modified
183557	57.207 Follow-up Laboratory Testing Form	Modified
183556	57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form	Modified
183555	57.125 Central Line Insertion Practices Adherence Monitoring Form Form	Modified
183554	57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form	Modified
183551	57.114 Urinary Tract Infection (UTI) Form and Instruction	Modified
183550	57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form	Modified
183549	57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Form and Instruction	Modified
183547	57.502 Dialysis Event Form and Instruction	Modified
183545	57.108 Primary Bloodstream Infection (BSI) Form and Instruction	Modified
183544	57.500 Outpatient Dialysis Center Practices Survey Form and Instruction	Modified
183543	57.203 Healthcare Personnel Safety Reporting Plan Form	Modified

ICR Details