Information Collection

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

IC 241810 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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: 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 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 %

table that charts list of burden
	Approved	Previously Approved
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

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.