Information Collection Request

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

ICR 202005-0920-004 · OMB 0920-1290 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry) Form and Instruction New Available
Form 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry) Form and Instruction New Available
Form 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry) Form and Instruction New Available
Form 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry) Form and Instruction New Available
Form 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry) Form and Instruction New Available
Form 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry) Form and Instruction New Available
Form 0920-1290 NHSN and Secure Access Management Services (SAMS) Enrollment Form and Instruction Unchanged Available
LTC Supplies and PPE Form Unchanged Available
LTC Supplies and PPE Form Unchanged Available
LTC Supplies Form Unchanged Available
LTC Ventilator Capacity Form Unchanged Available
LTC Ventilator Capacity Form Unchanged Available
LTC Ventilator Capacity Form Unchanged Available
LTC Resident impact Form Unchanged Available
LTC Resident Impact and Facility Capacity Form Unchanged Available
LTC Resident impact and facility capacity Form Unchanged Available
LTC Staff and Personnel Impact Form Unchanged Available
LTC Staff and Personnel Impact Form Unchanged Available
LTC Staff and Personnel Impact Form Unchanged Available
Form 0920-1290 COVID-19 Supplies Form Form and Instruction Unchanged Available
Form 0920-1290 COVID-19 Supplies Form Form and Instruction Unchanged Available
Form 0920-1290 COVID-19 Supplies Form Form and Instruction Unchanged Available
Form 0920-1290 COVID-19 Healthcare Worker Form Form and Instruction Unchanged Available
Form 0920-1290 COVID-19 Healthcare Worker Form Form and Instruction Unchanged Available
Form 0920-1290 COVID-19 Healthcare Worker Form Form and Instruction Unchanged Available
COVID-19 Patient Impact Module Form Form Unchanged Available
COVID-19 Patient Impact Module Form Form Unchanged Available
COVID-19 Patient Impact Module Form Form Unchanged Available
Change Request Memo 07MAY2020.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-05-12 Available
CDC 57.145_TOI_Staff and Personnel Impact (OMB)_6May2020_FINAL.docx Supplementary Document Uploaded 2020-05-07 Available
CDC 57.144_TOI_Resident Impact and Facility Capacity (OMB)_6May2020_FINAL.docx Supplementary Document Uploaded 2020-05-07 Available
Change Request Memo 07MAY2020.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-05-07 Available
CDC 57.147_TOI_Ventilator Capacity and Supplies.docx Supplementary Document Uploaded 2020-05-01 Available
CDC 57.146 TOI_Supplies and Personal Protective Equipment.docx Supplementary Document Uploaded 2020-05-01 Available
0920-1290 Change Memo - NHSN COVID-19 LTCF_4-30-20.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-05-01 Available
Supporting Statement A NHSN COVID-19_042220 clean.docx Supporting Statement A Uploaded 2020-04-23 Available
0920-1290 Change Request- NHSN COVID-19 LTCF_4-22-20 clean.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-04-23 Available
HDCommunication FINAL 10APR2020.docx Supplementary Document Uploaded 2020-04-10 Available
0920-1290 Change Request- NHSN COVID-19 Module 04092020.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-04-09 Available
Att4c_How to Enter and Access COVID Summary Data.docx Supplementary Document Uploaded 2020-03-24 Available
Revised Emergency Request Memo 23MAR2020.docx Supplementary Document Uploaded 2020-03-23 Available
Att6_NHSN Report of End of Human Research Review.docx Supplementary Document Uploaded 2020-03-23 Available
Att5_Closure of CDC Protocol 4062.docx Supplementary Document Uploaded 2020-03-23 Available
Att1c_42 USC 242m.pdf Supplementary Document Uploaded 2020-03-23 Available
Att1b_42 USC 242k.pdf Supplementary Document Uploaded 2020-03-23 Available
Att1a_42 USC 242b.pdf Supplementary Document Uploaded 2020-03-23 Available
Att3_PIA.pdf Supplementary Document Uploaded 2020-03-23 Available
Supporting Statement B NHSN COVID-19_clean.docx Supporting Statement B Uploaded 2020-03-24 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
241810 State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry) Form and Instruction NewCOVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
241809 Business and Financial Operations Occupations - Resident Impact/Facility Capacity Form - Retrospective Data Entry Form and Instruction NewCOVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
241808 LTCF Personnel - Resident Impact/Facility Capacity - Retrospective Data Entry Form and Instruction NewCOVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
241807 State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction NewCOVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
241806 Business and Financial Operations Occupations - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction NewCOVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
241805 LTCF Personnel - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction NewCOVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
241679 NHSN and Secure Access Management Services (SAMS) Enrollment Form and Instruction UnchangedNHSN and Secure Access Management Services (SAMS) Enrollment
241498 LTC Supplies and PPE - state/local health depts. Form UnchangedLTC Supplies and PPE
241497 LTC Supplies and PPE - business operations occupations Form UnchangedLTC Supplies and PPE
241496 LTC Supplies and PPE - microbiologists Form UnchangedLTC Supplies
241495 LTC Ventilator Capacity - state/local health depts. Form UnchangedLTC Ventilator Capacity
241494 LTC Ventilator Capacity - business operations occupations Form UnchangedLTC Ventilator Capacity
241493 LTC Ventilator Capacity - microbiologists Form UnchangedLTC Ventilator Capacity
241492 LTC Resident Impact - state/local health depts. Form UnchangedLTC Resident impact
241491 LTC Resident Impact - business operations occupations Form UnchangedLTC Resident Impact and Facility Capacity
241490 LTC Resident Impact - microbiologist Form UnchangedLTC Resident impact and facility capacity
241489 LTC Staff and Personnel Impact - state/local health depts. Form UnchangedLTC Staff and Personnel Impact
241488 LTC Staff and Personnel Impact - business operations occupations Form UnchangedLTC Staff and Personnel Impact
241487 LTC Staff and Personnel Impact - microbiologist Form UnchangedLTC Staff and Personnel Impact
241303 COVID-19 Supplies Form - State and Local Health Department Form and Instruction UnchangedCOVID-19 Supplies Form
241302 COVID-19 Supplies Form - Business/Financial Operations Form and Instruction UnchangedCOVID-19 Supplies Form
241301 COVID-19 Supplies Form - Microbiologist Form and Instruction UnchangedCOVID-19 Supplies Form
241300 COVID-19 Healthcare Worker Form - State and Local Health Department Form and Instruction UnchangedCOVID-19 Healthcare Worker Form
241299 COVID-19 Healthcare Worker Form - Business/Financial Operations Form and Instruction UnchangedCOVID-19 Healthcare Worker Form
241298 COVID-19 Healthcare Worker Form - Microbiologist Form and Instruction UnchangedCOVID-19 Healthcare Worker Form
241297 COVID-19 Patient Impact Module Form - State and Local Health Departments Instruction Unchanged
241297 COVID-19 Patient Impact Module Form - State and Local Health Departments Form UnchangedCOVID-19 Patient Impact Module Form
241296 COVID-19 Patient Impact Module Form - Business/Financial Operations Instruction Unchanged
241296 COVID-19 Patient Impact Module Form - Business/Financial Operations Form UnchangedCOVID-19 Patient Impact Module Form
240833 COVID-19 Patient Impact Module Form - Microbiologist Instruction Unchanged
240833 COVID-19 Patient Impact Module Form - Microbiologist Form UnchangedCOVID-19 Patient Impact Module Form

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
09/30/2020 09/30/2020 09/30/2020
3,235,450 0 3,220,776
1,066,226 0 1,062,556
0 0 0





Reginfo record details
28
table that charts list of burden
IC Title Form No. Form Name
Business and Financial Operations Occupations - Resident Impact/Facility Capacity Form - Retrospective Data Entry 0920-1290
Business and Financial Operations Occupations - Staff and Personnel Impact - Retrospective Data Entry 0920-1290
COVID-19 Healthcare Worker Form - Business/Financial Operations 0920-1290
COVID-19 Healthcare Worker Form - Microbiologist 0920-1290
COVID-19 Healthcare Worker Form - State and Local Health Department 0920-1290
COVID-19 Patient Impact Module Form - Business/Financial Operations NA
COVID-19 Patient Impact Module Form - Microbiologist NA
COVID-19 Patient Impact Module Form - State and Local Health Departments NA
COVID-19 Supplies Form - Business/Financial Operations 0920-1290
COVID-19 Supplies Form - Microbiologist 0920-1290
COVID-19 Supplies Form - State and Local Health Department 0920-1290
LTC Resident Impact - business operations occupations none
LTC Resident Impact - microbiologist none
LTC Resident Impact - state/local health depts. none
LTC Staff and Personnel Impact - business operations occupations none
LTC Staff and Personnel Impact - microbiologist none
LTC Staff and Personnel Impact - state/local health depts. none
LTC Supplies and PPE - business operations occupations none
LTC Supplies and PPE - microbiologists none
LTC Supplies and PPE - state/local health depts. none
LTC Ventilator Capacity - business operations occupations none
LTC Ventilator Capacity - microbiologists none
LTC Ventilator Capacity - state/local health depts. none
LTCF Personnel - Resident Impact/Facility Capacity - Retrospective Data Entry 0920-1290
LTCF Personnel - Staff and Personnel Impact - Retrospective Data Entry 0920-1290
NHSN and Secure Access Management Services (SAMS) Enrollment 0920-1290
State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry) 0920-1290
State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry 0920-1290

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 3,235,450 3,220,776 0 14,674 0 0
Annual Time Burden (Hours) 1,066,226 1,062,556 0 3,670 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No