State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry)

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

OMB: 0920-1290

IC ID: 241810

Information Collection (IC) Details

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State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry)
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry) CDC 57.144_TOI_Resident Impact and Facility Capacity (OMB) (002) lw CLEAN.docx NA Yes Yes Fillable Fileable

Health Health Care Services

 

1,223 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,223 0 1,223 0 0 0
Annual IC Time Burden (Hours) 306 0 306 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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