Change Request Justification 12MAY2020

Change Request Memo 07MAY2020.docx

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

Change Request Justification 12MAY2020

OMB: 0920-1290

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Change Memo for

“National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19)

Surveillance in Healthcare Facilities”

(OMB Control No. 0920-1290)

Expiration Date: 09/30/2020































Program Contact


Lauren Wattenmaker

Surveillance Branch

Division of Healthcare Quality Promotion

National Center for Emerging and Zoonotic Infectious Diseases

Centers for Disease Control and Prevention

Atlanta, Georgia 30333

Phone: 404-718-5842

Email: [email protected]


Submission Date: May 7, 2020

The Centers for Disease Control and Prevention (CDC), Division of Healthcare Quality Promotion (DHQP) requests a nonmaterial/non-substantive of the currently approved Information Collection Request: “National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities (OMB Control No. 0920-1290).”


This Change Request is submitted to include two additional revised versions of the following Instructions documents:

  1. Instructions for Completion of the COVID-19 Long-term Care Facility (LTCF): Resident Impact and Facility Capacity Form (CDC 57.144)

  2. Instructions for Completion of the COVID-19 Long-term Care Facility (LTCF): Staff and Personnel Impact Form (CDC 57.145)

Revisions contain a revised narrative that describes reporting requirements.

The burden associated with the retrospective data entry was increased as a result of the following modifications:

  1. Burden required for NHSN enrollment

  2. Burden required to find RETROSPECTIVE records related to:

    1. Staff and Personnel Impact

    2. Resident Impact / Facility Capacity

  3. Burden required to enter RETROSPECTIVE data into NHSN via the calendaring function


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorWattenmaker, Lauren (CDC/DDID/NCEZID/DHQP)
File Modified0000-00-00
File Created2021-01-14

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