Information Collection

COVID-19 Patient Impact Module Form - Microbiologist

IC 240833 under ICR 202005-0920-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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
COVID-19 Patient Impact Module Form - Microbiologist	Form
Att4b_Instructions for COVID-19 Patient Impact Module Form_clean.docx	Instruction
2. TOI_57.130_ v3_COVID19 patient impact and capacity FINAL.docx	Instruction
COVID-19 Patient Impact Module Form Att4a_COVID-19 Patient Impact Module Form_clean.docx	Form
0920-1290 COVID-19 Patient Impact Module Form - 14MAY2020 1. 57.130_v3_COVID-19_PIMHC_BLANK_FINAL.docx	Form

IC Title:

COVID-19 Patient Impact Module Form - Microbiologist

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	NA	COVID-19 Patient Impact Module Form	Att4a_COVID-19 Patient Impact Module Form_clean.docx	NA	Yes	Yes	Fillable Fileable
Instruction			Att4b_Instructions for COVID-19 Patient Impact Module Form_clean.docx		Yes	Yes	Fillable Fileable
Form	0920-1290	COVID-19 Patient Impact Module Form - 14MAY2020	1. 57.130_v3_COVID-19_PIMHC_BLANK_FINAL.docx	NA	Yes	Yes	Fillable Fileable
Instruction			2. TOI_57.130_ v3_COVID19 patient impact and capacity FINAL.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,079

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	374,220	0	374,220
Annual IC Time Burden (Hours)	218,295	62,370	155,925
Annual IC Cost Burden (Dollars)	0	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.