57.122 HAI Progress Report State Health Department Survey

[NCEZID] The National Healthcare Safety Network (NHSN)

Documents and Forms

Document Name Document Type
Form CDC 55.122 57.122 HAI Progress Report State Health Department Survey Form
CDC 55.122 State Health Department HAI Mandate and Validatyion Surv 57.122_ State Health Department HAI Mandate and Validation Survey_BLANK.docx Form
CDC 55.122 State Health Department HAI Mandate and Validatyion Surv 57.122_ State Health Department HAI Mandate and Validation Survey_BLANK.docx Form

Information Collection (IC) Details

IC Title:	57.122 HAI Progress Report State Health Department Survey	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 55.122	State Health Department HAI Mandate and Validatyion Survey	57.122_ State Health Department HAI Mandate and Validation Survey_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 55	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	55	55
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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