Information Collection Request

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

ICR 202006-0920-014 · OMB 0920-1290 · Historical Inactive

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 0920-1290 State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry) Form and Instruction Unchanged Available
Form 0920-1290 Business and Financial Operations Occupations - Resident Impact/Facility Capacity Form - Retrospective Data Entry Form and Instruction Unchanged Available
Form 0920-1290 LTCF Personnel - Resident Impact/Facility Capacity - Retrospective Data Entry Form and Instruction Unchanged Available
Form 0920-1290 State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction Unchanged Repair queued
Form 0920-1290 Business and Financial Operations Occupations - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction Unchanged Available
Form 0920-1290 LTCF Personnel - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction Unchanged Available
Form 0920-1290 NHSN and Secure Access Management Services (SAMS) Enrollment Form and Instruction Unchanged Repair queued
LTC Supplies and PPE - state/local health depts. Form Unchanged Available
LTC Supplies and PPE - business operations occupations Form Unchanged Repair queued
LTC Supplies and PPE - microbiologists Form Unchanged Repair queued
LTC Ventilator Capacity - state/local health depts. Form Unchanged Available
LTC Ventilator Capacity - business operations occupations Form Unchanged Repair queued
LTC Ventilator Capacity - microbiologists Form Unchanged Repair queued
LTC Resident Impact - state/local health depts. Form Unchanged Repair queued
LTC Resident Impact - business operations occupations Form Unchanged Repair queued
LTC Resident Impact - microbiologist Form Unchanged Available
LTC Staff and Personnel Impact - state/local health depts. Form Unchanged Available
LTC Staff and Personnel Impact - business operations occupations Form Unchanged Available
LTC Staff and Personnel Impact - microbiologist Form Unchanged Available
Form 0920-1290 COVID-19 Supplies Form - State and Local Health Department Form and Instruction Modified Repair queued
Form 0920-1290 COVID-19 Supplies Form - Business/Financial Operations Form and Instruction Modified Repair queued
Form 0920-1290 COVID-19 Supplies Form - Microbiologist Form and Instruction Modified Repair queued
Form 0920-1290 COVID-19 Healthcare Worker Form - State and Local Health Department Form and Instruction Unchanged Repair queued
Form 0920-1290 COVID-19 Healthcare Worker Form - Business/Financial Operations Form and Instruction Unchanged Repair queued
Form 0920-1290 COVID-19 Healthcare Worker Form - Microbiologist Form and Instruction Unchanged Available
COVID-19 Patient Impact Module Form - Business/Financial Operations Form Unchanged Available
Form 0920-1290 COVID-19 Patient Impact Module Form - Microbiologist Form Unchanged Repair queued
Hospital and Lab Data Submission FAQ UPDATED 062420_1248_withRed_Draft.docx Supplementary Document Uploaded 2020-07-01 Repair queued
0920-1290 Change Memo - NHSN COVID-19 supply changes FINAL.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-06-22 Repair queued
0920-1290 Change Memo - NHSN COVID-19 PIHC changes 05292020.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-05-29 Available
0920-1290 Change Memo - NHSN COVID-19 PIHC changes 050820.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-05-14 Available
3. Upcoming Additional and Modified Fields for Acute Care COVID-19 Module.pdf Supplementary Document Uploaded 2020-05-14 Available
4. BlastEmail_ allPSFacs for Friday morn_DRAFT_ (002) clean.docx Supplementary Document Uploaded 2020-05-14 Repair queued
Change Request Memo 07MAY2020.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-05-12 Repair queued
CDC 57.145_TOI_Staff and Personnel Impact (OMB)_6May2020_FINAL.docx Supplementary Document Uploaded 2020-05-07 Available
CDC 57.144_TOI_Resident Impact and Facility Capacity (OMB)_6May2020_FINAL.docx Supplementary Document Uploaded 2020-05-07 Available
Change Request Memo 07MAY2020.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-05-07 Repair queued
CDC 57.147_TOI_Ventilator Capacity and Supplies.docx Supplementary Document Uploaded 2020-05-01 Available
CDC 57.146 TOI_Supplies and Personal Protective Equipment.docx Supplementary Document Uploaded 2020-05-01 Available
0920-1290 Change Memo - NHSN COVID-19 LTCF_4-30-20.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-05-01 Repair queued
Supporting Statement A NHSN COVID-19_042220 clean.docx Supporting Statement A Uploaded 2020-04-23 Available
0920-1290 Change Request- NHSN COVID-19 LTCF_4-22-20 clean.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-04-23 Available
HDCommunication FINAL 10APR2020.docx Supplementary Document Uploaded 2020-04-10 Repair queued
0920-1290 Change Request- NHSN COVID-19 Module 04092020.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-04-09 Available
Att4c_How to Enter and Access COVID Summary Data.docx Supplementary Document Uploaded 2020-03-24 Repair queued
Revised Emergency Request Memo 23MAR2020.docx Supplementary Document Uploaded 2020-03-23 Repair queued
Att6_NHSN Report of End of Human Research Review.docx Supplementary Document Uploaded 2020-03-23 Available
Att5_Closure of CDC Protocol 4062.docx Supplementary Document Uploaded 2020-03-23 Repair queued
Att1c_42 USC 242m.pdf Supplementary Document Uploaded 2020-03-23 Available
Att1b_42 USC 242k.pdf Supplementary Document Uploaded 2020-03-23 Available
Att1a_42 USC 242b.pdf Supplementary Document Uploaded 2020-03-23 Repair queued
Att3_PIA.pdf Supplementary Document Uploaded 2020-03-23 Repair queued
Supporting Statement B NHSN COVID-19_clean.docx Supporting Statement B Uploaded 2020-03-24 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
242552 TeleTracking (TT) - U.S. Healthcare COVID-19 Portal New
241810 State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry) Form and Instruction Unchanged
241809 Business and Financial Operations Occupations - Resident Impact/Facility Capacity Form - Retrospective Data Entry Form and Instruction Unchanged
241808 LTCF Personnel - Resident Impact/Facility Capacity - Retrospective Data Entry Form and Instruction Unchanged
241807 State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction Unchanged
241806 Business and Financial Operations Occupations - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction Unchanged
241805 LTCF Personnel - Staff and Personnel Impact - Retrospective Data Entry Form and Instruction Unchanged
241679 NHSN and Secure Access Management Services (SAMS) Enrollment Form and Instruction Unchanged
241498 LTC Supplies and PPE - state/local health depts. Form Unchanged
241497 LTC Supplies and PPE - business operations occupations Form Unchanged
241496 LTC Supplies and PPE - microbiologists Form Unchanged
241495 LTC Ventilator Capacity - state/local health depts. Form Unchanged
241494 LTC Ventilator Capacity - business operations occupations Form Unchanged
241493 LTC Ventilator Capacity - microbiologists Form Unchanged
241492 LTC Resident Impact - state/local health depts. Form Unchanged
241491 LTC Resident Impact - business operations occupations Form Unchanged
241490 LTC Resident Impact - microbiologist Form Unchanged
241489 LTC Staff and Personnel Impact - state/local health depts. Form Unchanged
241488 LTC Staff and Personnel Impact - business operations occupations Form Unchanged
241487 LTC Staff and Personnel Impact - microbiologist Form Unchanged
241303 COVID-19 Supplies Form - State and Local Health Department Form and Instruction Modified
241302 COVID-19 Supplies Form - Business/Financial Operations Form and Instruction Modified
241301 COVID-19 Supplies Form - Microbiologist Form and Instruction Modified
241300 COVID-19 Healthcare Worker Form - State and Local Health Department Form and Instruction Unchanged
241299 COVID-19 Healthcare Worker Form - Business/Financial Operations Form and Instruction Unchanged
241298 COVID-19 Healthcare Worker Form - Microbiologist Form and Instruction Unchanged
241297 COVID-19 Patient Impact Module Form - State and Local Health Departments Instruction Unchanged
241296 COVID-19 Patient Impact Module Form - Business/Financial Operations Form Unchanged
240833 COVID-19 Patient Impact Module Form - Microbiologist Form Unchanged

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
09/30/2020 09/30/2020 09/30/2020
3,235,450 0 3,235,450
1,206,491 0 1,206,491
0 0 0





Reginfo record details
29
table that charts list of burden
IC Title Form No. Form Name
TeleTracking (TT) - U.S. Healthcare COVID-19 Portal
LTC Supplies and PPE - business operations occupations none LTC Supplies and PPE
COVID-19 Healthcare Worker Form - Microbiologist 0920-1290 COVID-19 Healthcare Worker Form
COVID-19 Healthcare Worker Form - Business/Financial Operations 0920-1290 COVID-19 Healthcare Worker Form
COVID-19 Supplies Form - State and Local Health Department 0920-1290, 0920-1290 COVID-19 Supplies Form ,   COVID-19 Module - Hospital Supply Pathway 19JUN2020
COVID-19 Patient Impact Module Form - Microbiologist 0920-1290, 00920-1290, NA COVID-19 Patient Impact Module Form - 14MAY2020 ,   COVID-19 Patient Impact Module Form ,   COVID-19 Patient Impact Module Form 29MAY2020
COVID-19 Patient Impact Module Form - State and Local Health Departments 0920-1290, 0920-1290, NA COVID-19 Patient Impact Module Form ,   COVID-19 Patient Impact Module Form - 14MAY2020 ,   COVID-19 Patient Impact Module Form 29MAY2020
COVID-19 Healthcare Worker Form - State and Local Health Department 0920-1290 COVID-19 Healthcare Worker Form
COVID-19 Supplies Form - Microbiologist 0920-1290, 0920-1290 COVID-19 Supplies Form ,   COVID-19 Module - Hospital Supply Pathway 19JUN2020
LTC Supplies and PPE - microbiologists none LTC Supplies
LTC Ventilator Capacity - state/local health depts. none LTC Ventilator Capacity
COVID-19 Supplies Form - Business/Financial Operations 0920-1290, 0920-1290 COVID-19 Supplies Form ,   COVID-19 Module - Hospital Supply Pathway 19JUN2020
COVID-19 Patient Impact Module Form - Business/Financial Operations 0920-1290, 09201290, NA COVID-19 Patient Impact Module Form ,   COVID-19 Patient Impact Module Form - 14MAY2020 ,   COVID-19 Patient Impact Module Form 29MAY2020
LTC Supplies and PPE - state/local health depts. none LTC Supplies and PPE
NHSN and Secure Access Management Services (SAMS) Enrollment 0920-1290 NHSN and Secure Access Management Services (SAMS) Enrollment
LTCF Personnel - Staff and Personnel Impact - Retrospective Data Entry 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
Business and Financial Operations Occupations - Staff and Personnel Impact - Retrospective Data Entry 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
Business and Financial Operations Occupations - Resident Impact/Facility Capacity Form - Retrospective Data Entry 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry) 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
LTC Staff and Personnel Impact - microbiologist none LTC Staff and Personnel Impact
LTC Staff and Personnel Impact - business operations occupations none LTC Staff and Personnel Impact
LTC Staff and Personnel Impact - state/local health depts. none LTC Staff and Personnel Impact
LTC Resident Impact - microbiologist none LTC Resident impact and facility capacity
LTCF Personnel - Resident Impact/Facility Capacity - Retrospective Data Entry 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
LTC Resident Impact - business operations occupations none LTC Resident Impact and Facility Capacity
LTC Resident Impact - state/local health depts. none LTC Resident impact
LTC Ventilator Capacity - microbiologists none LTC Ventilator Capacity
LTC Ventilator Capacity - business operations occupations none LTC Ventilator Capacity



Reginfo record details
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