COVID-19 Patient Impact Module Form

National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1290 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-20LW COVID-19 Patient Impact Module Form Form
Att4b_Instructions for COVID-19 Patient Impact Module Form_clean.docx Instruction
0920-20LW COVID-19 Patient Impact Module Form Att4a_COVID-19 Patient Impact Module Form_clean.docx Form

Information Collection (IC) Details

IC Title:	COVID-19 Patient Impact Module Form	Agency IC Tracking Number:	0920-20LW

Is this a Common Form? No		IC Status: New

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	0920-20LW	COVID-19 Patient Impact Module Form	Att4a_COVID-19 Patient Impact Module Form_clean.docx		Yes	Yes	Fillable Fileable
Instruction			Att4b_Instructions for COVID-19 Patient Impact Module Form_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,900	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	702,000	702,000
Annual IC Time Burden (Hours)	234,000	234,000
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.