Information Collection

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

IC 241300 under ICR 202005-0920-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.