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 State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry) Form and Instruction New Available
Form 0920-1290 Business and Financial Operations Occupations - Resident Impact/Facility Capacity Form - Retrospective Data Entry Form and Instruction New Available
Form 0920-1290 LTCF Personnel - Resident Impact/Facility Capacity - Retrospective Data Entry Form and Instruction New Available
Form 0920-1290 State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction New Available
Form 0920-1290 Business and Financial Operations Occupations - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction New Available
Form 0920-1290 LTCF Personnel - Staff and Personnel Impact - Retrospective Data 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 - state/local health depts. Form Unchanged Available
LTC Supplies and PPE - business operations occupations Form Unchanged Available
LTC Supplies and PPE - microbiologists Form Unchanged Available
LTC Ventilator Capacity - state/local health depts. Form Unchanged Available
LTC Ventilator Capacity - business operations occupations Form Unchanged Available
LTC Ventilator Capacity - microbiologists Form Unchanged Available
LTC Resident Impact - state/local health depts. Form Unchanged Available
LTC Resident Impact - business operations occupations Form Unchanged Available
LTC Resident Impact - microbiologist Form Unchanged Available
LTC Staff and Personnel Impact - state/local health depts. Form Unchanged Available
LTC Staff and Personnel Impact - business operations occupations Form Unchanged Available
LTC Staff and Personnel Impact - microbiologist Form Unchanged Available
Form 0920-1290 COVID-19 Supplies Form - State and Local Health Department Form and Instruction Unchanged Available
Form 0920-1290 COVID-19 Supplies Form - Business/Financial Operations Form and Instruction Unchanged Available
Form 0920-1290 COVID-19 Supplies Form - Microbiologist Form and Instruction Unchanged Available
Form 0920-1290 COVID-19 Healthcare Worker Form - State and Local Health Department Form and Instruction Unchanged Available
Form 0920-1290 COVID-19 Healthcare Worker Form - Business/Financial Operations Form and Instruction Unchanged Available
Form 0920-1290 COVID-19 Healthcare Worker Form - Microbiologist Form and Instruction Unchanged Available
COVID-19 Patient Impact Module Form - State and Local Health Departments Form Unchanged Available
COVID-19 Patient Impact Module Form - Business/Financial Operations Form Unchanged Available
COVID-19 Patient Impact Module Form - Microbiologist 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 Repair queued
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 New
241809 Business and Financial Operations Occupations - Resident Impact/Facility Capacity Form - Retrospective Data Entry Form and Instruction New
241808 LTCF Personnel - Resident Impact/Facility Capacity - Retrospective Data Entry Form and Instruction New
241807 State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction New
241806 Business and Financial Operations Occupations - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction New
241805 LTCF Personnel - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction New
241679 NHSN and Secure Access Management Services (SAMS) Enrollment Form and Instruction Unchanged
241498 LTC Supplies and PPE - state/local health depts. Form Unchanged
241497 LTC Supplies and PPE - business operations occupations Form Unchanged
241496 LTC Supplies and PPE - microbiologists Form Unchanged
241495 LTC Ventilator Capacity - state/local health depts. Form Unchanged
241494 LTC Ventilator Capacity - business operations occupations Form Unchanged
241493 LTC Ventilator Capacity - microbiologists Form Unchanged
241492 LTC Resident Impact - state/local health depts. Form Unchanged
241491 LTC Resident Impact - business operations occupations Form Unchanged
241490 LTC Resident Impact - microbiologist Form Unchanged
241489 LTC Staff and Personnel Impact - state/local health depts. Form Unchanged
241488 LTC Staff and Personnel Impact - business operations occupations Form Unchanged
241487 LTC Staff and Personnel Impact - microbiologist Form Unchanged
241303 COVID-19 Supplies Form - State and Local Health Department Form and Instruction Unchanged
241302 COVID-19 Supplies Form - Business/Financial Operations Form and Instruction Unchanged
241301 COVID-19 Supplies Form - Microbiologist Form and Instruction Unchanged
241300 COVID-19 Healthcare Worker Form - State and Local Health Department Form and Instruction Unchanged
241299 COVID-19 Healthcare Worker Form - Business/Financial Operations Form and Instruction Unchanged
241298 COVID-19 Healthcare Worker Form - Microbiologist Form and Instruction Unchanged
241297 COVID-19 Patient Impact Module Form - State and Local Health Departments Form Unchanged
241296 COVID-19 Patient Impact Module Form - Business/Financial Operations Form Unchanged
240833 COVID-19 Patient Impact Module Form - Microbiologist Form Unchanged

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
NHSN and Secure Access Management Services (SAMS) Enrollment 0920-1290 NHSN and Secure Access Management Services (SAMS) Enrollment
LTC Ventilator Capacity - business operations occupations none LTC Ventilator Capacity
LTC Ventilator Capacity - state/local health depts. none LTC Ventilator Capacity
LTC Resident Impact - microbiologist none LTC Resident impact and facility capacity
LTC Resident Impact - business operations occupations none LTC Resident Impact and Facility Capacity
LTC Supplies and PPE - microbiologists none LTC Supplies
LTC Resident Impact - state/local health depts. none LTC Resident impact
LTC Ventilator Capacity - microbiologists none LTC Ventilator Capacity
LTC Supplies and PPE - business operations occupations none LTC Supplies and PPE
COVID-19 Healthcare Worker Form - Microbiologist 0920-1290 COVID-19 Healthcare Worker Form
COVID-19 Healthcare Worker Form - Business/Financial Operations 0920-1290 COVID-19 Healthcare Worker Form
COVID-19 Healthcare Worker Form - State and Local Health Department 0920-1290 COVID-19 Healthcare Worker Form
COVID-19 Supplies Form - Microbiologist 0920-1290 COVID-19 Supplies Form
COVID-19 Supplies Form - State and Local Health Department 0920-1290 COVID-19 Supplies Form
COVID-19 Patient Impact Module Form - Microbiologist NA COVID-19 Patient Impact Module Form
COVID-19 Patient Impact Module Form - State and Local Health Departments NA COVID-19 Patient Impact Module Form
COVID-19 Supplies Form - Business/Financial Operations 0920-1290 COVID-19 Supplies Form
LTCF Personnel - Staff and Personnel Impact - Retrospective Data Entry 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
Business and Financial Operations Occupations - Staff and Personnel Impact - Retrospective Data Entry 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
LTCF Personnel - Resident Impact/Facility Capacity - Retrospective Data Entry 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
Business and Financial Operations Occupations - Resident Impact/Facility Capacity Form - Retrospective Data Entry 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry) 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
LTC Staff and Personnel Impact - microbiologist none LTC Staff and Personnel Impact
LTC Staff and Personnel Impact - business operations occupations none LTC Staff and Personnel Impact
LTC Staff and Personnel Impact - state/local health depts. none LTC Staff and Personnel Impact
COVID-19 Patient Impact Module Form - Business/Financial Operations NA COVID-19 Patient Impact Module Form
LTC Supplies and PPE - state/local health depts. none LTC Supplies and PPE

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