[NCEZID] The National Healthcare Safety Network (NHSN)

ICR 202502-0920-016

OMB: 0920-0666

Federal Form Document

Forms and Documents

Document Name	Status
Form 57.106 57.106 Patient Safety Monthly Reporting Plan Form and Instruction	Unchanged
Form 57.803 All Hazards Form and Instruction	Unchanged
Form 57.802 Bed Capacity-IT Initial Set Up Form and Instruction	Unchanged
Form 57.801 External Validation Summary Report Form and Instruction	Unchanged
Form 57.215 Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel Form and Instruction	Unchanged
Form 57.214 Annual Healthcare Personnel Influenza Vaccination Summary (CSV) Form	Unchanged
Form 57.211 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities (CSV) Form	Unchanged
Form 57.133 Patient Safety Attestation Form and Instruction	Unchanged
Form 57.130 57.130 Pathogens of High Consequence Form and Instruction	Unchanged
Form 57.124 AUR Pharmacy Data Electronic Upload Specification Tables (Yearly Maintenance) Form	Unchanged
Form 57.124 AUR Pharmacy Data Electronic Upload Specification Tables (Initial Set-up) Form	Unchanged
Form 57.123 AUR Microbiolgy Data Electronic Upload Specification Tables (Yearly Maintenance) Form	Unchanged
Form 57.123 AUR Microbiology Data Electronic Upload Specification Tables (Initial Set-up) Form	Unchanged
Form 57.102 NHSN Help Desk Customer Satisfaction Survey Form and Instruction	Unchanged
Form CDC 57.302 Hemovigilance Module Monthly Incident Summary Form and Instruction	Unchanged
Form 57.800 Billing Code Data: 837I Upload Form	Modified
Form 57.701 57.701 - Glycemic Control Module-HYPO Annual Survey Form and Instruction	Modified
Form 57.700 57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist Form and Instruction	Unchanged
Form 57.700 57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance Form and Instruction	Unchanged
Form 57.700 57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Initial Set up Form and Instruction	Unchanged
Form 57.600 57.600 - Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist Form and Instruction	Unchanged
Form 57.600 57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist Form and Instruction	Unchanged
Form 57.600 57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance Form and Instruction	Unchanged
Form 57.600 57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up Form and Instruction	Unchanged
Form 57.145 57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA Form and Instruction	Modified
Form 57.132 57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist Form and Instruction	Unchanged
Form 57.132 57.132 - Patient Safety Digital Reporting Plan (RPS CSV) Form and Instruction	Unchanged
Form 57.408 Monthly Survey Patient Days & Nurse Staffing Form and Instruction	Unchanged
Form CDC 57.214 Annual Healthcare Personnel Influenza Vaccination Summary (manual) Form and Instruction	Unchanged
Form CDC 57.211 Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities Form and Instruction	Unchanged
Form 57.601 Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) Form and Instruction	Modified
Form 57.602 Long Term Care Facility Component - Respiratory Tract Infection Form and Instruction	Modified
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	Unchanged
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 CDC 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 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 57.504 57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form	Unchanged
Form CDC 57.501 57.501 Dialysis Monthly Reporting Plan Form	Unchanged
Form CDC 57.403 57.403 Outpatient Procedure Component - Monthly Denominators and Summary Form	Unchanged
Form CDC 57.402 57.402 Outpatient Procedure Component Event Form	Modified
Form CDC 57.401 57.401 Outpatient Procedure - Monthly Reporting Plan Form	Unchanged
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey Form	Unchanged
Form 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form and Instruction	Unchanged
Form 57.150 57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form and Instruction	Unchanged
Form CDC 57.143 57.143 Prevention Process Measures Monthly Monitoring for LTCF Form	Unchanged
Form CDC 57.142 57.142 Denominators for LTCF Locations Form	Unchanged
Form CDC 57.141 57.141 Monthly Reporting Plan for LTCF Form	Unchanged
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	Unchanged
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	Unchanged
Form CDC 57.305 57.305 Hemovigilance Incident Form	Unchanged
Form CDC 57.303 57.303 Hemovigilance Module Monthly Reporting Denominators Form and Instruction	Unchanged
Form 57.301 57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction	Unchanged
Form CDC 57.300 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form	Modified
Form CDC 57.105 57.105 Group Contact Information Form	Unchanged
Form 57.140 57.140 Urinary Tract Infection (UTI) for LTCF Form and Instruction	Modified
Form 57.103 57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction	Unchanged
Form CDC 57.101 57.101 Facility Contact Information Form	Unchanged
Form 57.124 57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Form and Instruction	Unchanged
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	Unchanged
Form 57.121 57.121 Denominators for Procedure Form and Instruction	Modified
Form 57.128 57.128 Laboratory Identified or CDI MDRO Event Form	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	Unchanged
Form CDC 57.127 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form	Unchanged
Form CDC 57.118 57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Form	Unchanged
Form CDC 57.117 57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form	Unchanged
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	Unchanged
Form 57.114 57.114 Urinary Tract Infection (UTI) Form and Instruction	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	Unchanged
Change Request Memo - EO14168.docx Justification for No Material/Nonsubstantive Change	2025-03-05
Emergency Request Memo_23DEC2024.docx Supplementary Document	2024-12-23
G3. Privacy Impact Assessment_NHSN_PIA_Signed_2023-01-19.pdf Supplementary Document	2024-12-23
Human Subject Determination-IRB approval.pdf Supplementary Document	2024-12-23
Copy of 2025 OMB FHIR RPS Data Dictionary_JAN_2025_UPDATES.xlsx Supplementary Document	2025-03-05
Copy of 2025 OMB FHIR ACH Monthly Measures Data Dictionary_JAN_2025_UPDATES.xlsx Supplementary Document	2025-03-05
G3. Privacy Impact Assessment_NHSN_PIA_Signed_2023-01-19.pdf Supplementary Document	2024-10-31
G2. Privacy Impact Assessment_ NHSN2-Cloud_PIA_Signed_2023-12-05_eRAP.pdf Supplementary Document	2024-10-31
G1. Privacy Impact Assessment.pdf Supplementary Document	2024-10-31
F2. NHSN 308d Request for Extension and Ammendment.docx Supplementary Document	2024-10-31
F1. NHSN 308d Approval 2015.pdf Supplementary Document	2024-10-31
E3. Human Subjects Determination_2.pdf Supplementary Document	2024-10-31
E2. Report of End of Human Research Review 0.1253.docx Supplementary Document	2024-10-31
E1. Closure CDC Protocol # 4062.docx Supplementary Document	2024-10-31
D2. Explanation for Program Changes or Adjustments 2024-0920-0666.docx Supplementary Document	2024-10-31
D1. Explanation for Program Changes or Adjustments 2024-0920-0666_v2.docx Supplementary Document	2024-10-31
B. 60-Day Published Federal Register Notice.pdf Supplementary Document	2024-10-30
A3. 42 USC 242m.pdf Supplementary Document	2024-10-30
A2. 42 USC 242k.pdf Supplementary Document	2024-10-30
A1. 42 USC 242b.pdf Supplementary Document	2024-10-30
Supporting Statement B.docx Supporting Statement B	2024-12-23
Supporting Statement A.docx Supporting Statement A	2024-12-23

IC Document Collections

IC ID	Document Title	Status
7134	57.106 Patient Safety Monthly Reporting Plan Form and Instruction	Unchanged
272124	All Hazards Form and Instruction	Unchanged
272123	Bed Capacity-IT Initial Set Up Form and Instruction	Unchanged
272122	External Validation Summary Report Form and Instruction	Unchanged
272108	Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel Form and Instruction	Unchanged
272105	Annual Healthcare Personnel Influenza Vaccination Summary (CSV) Form	Unchanged
272101	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities (CSV) Form	Unchanged
272031	Patient Safety Attestation Form and Instruction	Unchanged
272029	57.130 Pathogens of High Consequence Form and Instruction	Unchanged
272027	AUR Pharmacy Data Electronic Upload Specification Tables (Yearly Maintenance) Form	Unchanged
272026	AUR Pharmacy Data Electronic Upload Specification Tables (Initial Set-up) Form	Unchanged
272025	AUR Microbiolgy Data Electronic Upload Specification Tables (Yearly Maintenance) Form	Unchanged
272024	AUR Microbiology Data Electronic Upload Specification Tables (Initial Set-up) Form	Unchanged
272017	NHSN Help Desk Customer Satisfaction Survey Form and Instruction	Unchanged
265665	Hemovigilance Module Monthly Incident Summary Form and Instruction	Unchanged
263469	Billing Code Data: 837I Upload Form	Modified
263468	57.701 - Glycemic Control Module-HYPO Annual Survey Form and Instruction	Modified
263467	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-Infection Preventionist Form and Instruction	Unchanged
263466	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Yearly Maintenance Form and Instruction	Unchanged
263465	57.700 - Medication Safety Component FHIR Measure-Glycemic Control Module Hypoglycemia-IT Initial Set up Form and Instruction	Unchanged
263464	57.600 - Neonatal Component Late Onset Sepsis Meningitis (LOSMEN) Module CDA Data Collection-Infection Preventionist Form and Instruction	Unchanged
263463	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-Infection Preventionist Form and Instruction	Unchanged
263462	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Yearly Maintenance Form and Instruction	Unchanged
263461	57.600 - Neonatal Component FHIR Measure-Late Onset Sepsis Meningitis (LOSMEN) Module-IT Initial Set up Form and Instruction	Unchanged
263460	57.145 - Long Term Care Antimicrobial Use (LTC-AU) Module CDA Form and Instruction	Modified
263453	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-Infection Preventionist Form and Instruction	Unchanged
263452	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Yearly Maintenance Other-OMB Header and Burden Statement	Unchanged
263450	57.132 - Patient Safety Component FHIR Measures-HOB, HT-CDI Modules-IT Initial Set up Other-OMB Header and Burden Statement	Unchanged
263449	57.132 - Patient Safety Digital Reporting Plan (RPS CSV) Form and Instruction	Unchanged
257463	Monthly Survey Patient Days & Nurse Staffing Form and Instruction	Unchanged
246758	Annual Healthcare Personnel Influenza Vaccination Summary (manual) Form and Instruction	Unchanged
246755	Weekly Healthcare Personnel Influenza Vaccination Cumulative Summary for Non-Long-Term Care Facilities Form and Instruction	Unchanged
244476	Late Onset Sepsis/Meningitis Denominator Form: Data Table (Monthly) Form and Instruction	Modified
238093	Long Term Care Facility Component - Respiratory Tract Infection Form and Instruction	Modified
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	Unchanged
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 Form	Modified
222891	57.115 Custom Event Form	Modified
222890	57.113 Pediatric Ventilator-Associated Event (PedVAE) Form and Instruction	Modified
208409	57.504 Prevention Process Measures Monthly Monitoring for Dialysis Form	Unchanged
208408	57.501 Dialysis Monthly Reporting Plan Form	Unchanged
208407	57.403 Outpatient Procedure Component - Monthly Denominators and Summary Form	Unchanged
208406	57.402 Outpatient Procedure Component Event Form	Modified
208405	57.401 Outpatient Procedure - Monthly Reporting Plan Form	Unchanged
208404	57.400 Outpatient Procedure - Annual Facility Survey Form	Unchanged
200382	57.151 Patient Safety Component -- Annual Facility Survey for IRF Form and Instruction	Unchanged
200381	57.150 Patient Safety Component -- Annual Facility Survey for LTAC Form and Instruction	Unchanged
200380	57.143 Prevention Process Measures Monthly Monitoring for LTCF Form	Unchanged
200379	57.142 Denominators for LTCF Locations Form	Unchanged
200378	57.141 Monthly Reporting Plan for LTCF Form	Unchanged
200377	57.112 Ventilator-Associated Event (VAE) Form and Instruction	Modified
197543	57.139 MDRO and CDI Prevention Process Measures Monthly for LTCF Form	Unchanged
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	Unchanged
190364	57.305 Hemovigilance Incident Form	Unchanged
190363	57.303 Hemovigilance Module Monthly Reporting Denominators Form and Instruction	Unchanged
190361	57.301 Hemovigilance Module Monthly Reporting Plan Form and Instruction	Unchanged
190360	57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form	Modified
183576	57.105 Group Contact Information Form	Unchanged
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	Unchanged
183570	57.101 Facility Contact Information Form	Unchanged
183568	57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Form and Instruction	Unchanged
183566	57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Form and Instruction	Modified
183565	57.100 NHSN Registration Form Form	Unchanged
183564	57.121 Denominators for Procedure Form and Instruction	Modified
183563	57.128 Laboratory Identified or CDI MDRO Event Form	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	Unchanged
183559	57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Form	Unchanged
183558	57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Form	Unchanged
183556	57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Form	Unchanged
183555	57.125 Central Line Insertion Practices Adherence Monitoring Form Form	Modified
183554	57.116 Denominators for Neonatal Intensive Care Unit (NICU) Form	Unchanged
183551	57.114 Urinary Tract Infection (UTI) Form and Instruction	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	Unchanged