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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1290 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1290 State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry) Form and Instruction
0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capa CDC 57.144_TOI_Resident Impact and Facility Capacity (OMB) (002) lw CLEAN.docx Form and Instruction

Information Collection (IC) Details

IC Title:	State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,223	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,223	1,223
Annual IC Time Burden (Hours)	306	306
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.