Information Collection

COVID-19 Healthcare Worker Form - State and Local Health Department

IC 241300 under ICR 202004-0920-017 · OMB 0920-1290.

⚠️ Notice: This information collection may be referencing outdated material.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 0920-1290 COVID-19 Healthcare Worker Form - State and Local Health Department Form and Instruction
0920-1290 COVID-19 Healthcare Worker Form Att7_NHSN COVID-19 Module Healthcare Worker Staffing Form.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	COVID-19 Healthcare Worker Form - State and Local Health Department	Agency IC Tracking Number:

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 and Instruction	0920-1290	COVID-19 Healthcare Worker Form	Att7_NHSN COVID-19 Module Healthcare Worker Staffing Form.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: 519	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	93,420	93,420
Annual IC Time Burden (Hours)	38,925	38,925
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.