COVID-19 Patient Impact Module Form - State and Local Health Departments

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⚠️ Notice: This information collection may be referencing outdated material.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
COVID-19 Patient Impact Module Form - State and Local Health Departments 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
TOI_57.130_ v4_COVID19 patient impact and capacity CLEAN.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
0920-1290 COVID-19 Patient Impact Module Form 29MAY2020 57.130_v4_COVID-19_PIMHC_BLANK_CLEAN.docx Form

Information Collection (IC) Details

IC Title:	COVID-19 Patient Impact Module Form - State and Local Health Departments	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	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	NA	Yes	Yes	Fillable Fileable
Form	0920-1290	COVID-19 Patient Impact Module Form 29MAY2020	57.130_v4_COVID-19_PIMHC_BLANK_CLEAN.docx	NA	Yes	Yes	Fillable Fileable
Instruction			TOI_57.130_ v4_COVID19 patient impact and capacity CLEAN.docx	NA	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: 519	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	Previously Approved
Annual Number of Responses for this IC	93,420	0	93,420
Annual IC Time Burden (Hours)	62,280	7,785	54,495
Annual IC Cost Burden (Dollars)	0	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.