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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)	Form and Instruction	Unchanged	Available
Form 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)	Form and Instruction	Unchanged	Available
Form 0920-1290 COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)	Form and Instruction	Unchanged	Available
Form 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)	Form and Instruction	Unchanged	Repair queued
Form 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)	Form and Instruction	Unchanged	Available
Form 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat 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	Form	Unchanged	Available
LTC Supplies and PPE	Form	Unchanged	Repair queued
LTC Supplies	Form	Unchanged	Repair queued
LTC Ventilator Capacity	Form	Unchanged	Available
LTC Ventilator Capacity	Form	Unchanged	Available
LTC Ventilator Capacity	Form	Unchanged	Repair queued
LTC Resident impact	Form	Unchanged	Repair queued
LTC Resident Impact and Facility Capacity	Form	Unchanged	Repair queued
LTC Resident impact and facility capacity	Form	Unchanged	Available
LTC Staff and Personnel Impact	Form	Unchanged	Available
LTC Staff and Personnel Impact	Form	Unchanged	Available
LTC Staff and Personnel Impact	Form	Unchanged	Available
Form 0920-1290 COVID-19 Module - Hospital Supply Pathway 19JUN2020	Form and Instruction	Modified	Available
Form 0920-1290 COVID-19 Supplies Form	Form and Instruction	Modified	Repair queued
Form 0920-1290 COVID-19 Module - Hospital Supply Pathway 19JUN2020	Form and Instruction	Modified	Available
Form 0920-1290 COVID-19 Supplies Form	Form and Instruction	Modified	Repair queued
Form 0920-1290 COVID-19 Module - Hospital Supply Pathway 19JUN2020	Form and Instruction	Modified	Available
Form 0920-1290 COVID-19 Supplies Form	Form and Instruction	Modified	Repair queued
Form 0920-1290 COVID-19 Healthcare Worker Form	Form and Instruction	Unchanged	Repair queued
Form 0920-1290 COVID-19 Healthcare Worker Form	Form and Instruction	Unchanged	Available
Form 0920-1290 COVID-19 Healthcare Worker Form	Form and Instruction	Unchanged	Available
Form 0920-1290 COVID-19 Patient Impact Module Form 29MAY2020	Form	Unchanged	Available
Form 0920-1290 COVID-19 Patient Impact Module Form - 14MAY2020	Form	Unchanged	Available
COVID-19 Patient Impact Module Form	Form	Unchanged	Available
Form 09201290 COVID-19 Patient Impact Module Form 29MAY2020	Form	Unchanged	Available
Form 0920-1290 COVID-19 Patient Impact Module Form - 14MAY2020	Form	Unchanged	Available
COVID-19 Patient Impact Module Form	Form	Unchanged	Available
Form 00920-1290 COVID-19 Patient Impact Module Form 29MAY2020	Form	Unchanged	Available
Form 0920-1290 COVID-19 Patient Impact Module Form - 14MAY2020	Form	Unchanged	Repair queued
COVID-19 Patient Impact Module Form	Form	Unchanged	Available
Hospital and Lab Data Submission FAQ UPDATED 062420_1248_withRed_Draft.docx	Supplementary Document	Uploaded 2020-07-01	Available
0920-1290 Change Memo - NHSN COVID-19 supply changes FINAL.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-06-22	Available
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	Available
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	Available
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	Available
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	Available
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	Available
Att3_PIA.pdf	Supplementary Document	Uploaded 2020-03-23	Available
Supporting Statement B NHSN COVID-19_clean.docx	Supporting Statement B	Uploaded 2020-03-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
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	COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
241809	Business and Financial Operations Occupations - Resident Impact/Facility Capacity Form - Retrospective Data Entry	Form and Instruction	Unchanged	COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
241808	LTCF Personnel - Resident Impact/Facility Capacity - Retrospective Data Entry	Form and Instruction	Unchanged	COVID-19 Module - LTCF Resident Impact and Facility Capacity Form (Retrospective Datat Entry)
241807	State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry	Form and Instruction	Unchanged	COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
241806	Business and Financial Operations Occupations - Staff and Personnel Impact - Retrospective Data Entry	Form and Instruction	Unchanged	COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
241805	LTCF Personnel - Staff and Personnel Impact - Retrospective Data Entry	Form and Instruction	Unchanged	COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)
241679	NHSN and Secure Access Management Services (SAMS) Enrollment	Form and Instruction	Unchanged	NHSN and Secure Access Management Services (SAMS) Enrollment
241498	LTC Supplies and PPE - state/local health depts.	Form	Unchanged	LTC Supplies and PPE
241497	LTC Supplies and PPE - business operations occupations	Form	Unchanged	LTC Supplies and PPE
241496	LTC Supplies and PPE - microbiologists	Form	Unchanged	LTC Supplies
241495	LTC Ventilator Capacity - state/local health depts.	Form	Unchanged	LTC Ventilator Capacity
241494	LTC Ventilator Capacity - business operations occupations	Form	Unchanged	LTC Ventilator Capacity
241493	LTC Ventilator Capacity - microbiologists	Form	Unchanged	LTC Ventilator Capacity
241492	LTC Resident Impact - state/local health depts.	Form	Unchanged	LTC Resident impact
241491	LTC Resident Impact - business operations occupations	Form	Unchanged	LTC Resident Impact and Facility Capacity
241490	LTC Resident Impact - microbiologist	Form	Unchanged	LTC Resident impact and facility capacity
241489	LTC Staff and Personnel Impact - state/local health depts.	Form	Unchanged	LTC Staff and Personnel Impact
241488	LTC Staff and Personnel Impact - business operations occupations	Form	Unchanged	LTC Staff and Personnel Impact
241487	LTC Staff and Personnel Impact - microbiologist	Form	Unchanged	LTC Staff and Personnel Impact
241303	COVID-19 Supplies Form - State and Local Health Department	Form and Instruction	Modified	COVID-19 Module - Hospital Supply Pathway 19JUN2020
241303	COVID-19 Supplies Form - State and Local Health Department	Form and Instruction	Modified	COVID-19 Supplies Form
241302	COVID-19 Supplies Form - Business/Financial Operations	Form and Instruction	Modified	COVID-19 Module - Hospital Supply Pathway 19JUN2020
241302	COVID-19 Supplies Form - Business/Financial Operations	Form and Instruction	Modified	COVID-19 Supplies Form
241301	COVID-19 Supplies Form - Microbiologist	Form and Instruction	Modified	COVID-19 Module - Hospital Supply Pathway 19JUN2020
241301	COVID-19 Supplies Form - Microbiologist	Form and Instruction	Modified	COVID-19 Supplies Form
241300	COVID-19 Healthcare Worker Form - State and Local Health Department	Form and Instruction	Unchanged	COVID-19 Healthcare Worker Form
241299	COVID-19 Healthcare Worker Form - Business/Financial Operations	Form and Instruction	Unchanged	COVID-19 Healthcare Worker Form
241298	COVID-19 Healthcare Worker Form - Microbiologist	Form and Instruction	Unchanged	COVID-19 Healthcare Worker Form
241297	COVID-19 Patient Impact Module Form - State and Local Health Departments	Form	Unchanged	COVID-19 Patient Impact Module Form 29MAY2020
241297	COVID-19 Patient Impact Module Form - State and Local Health Departments	Form	Unchanged	COVID-19 Patient Impact Module Form - 14MAY2020
241297	COVID-19 Patient Impact Module Form - State and Local Health Departments	Form	Unchanged	COVID-19 Patient Impact Module Form
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	COVID-19 Patient Impact Module Form 29MAY2020
241296	COVID-19 Patient Impact Module Form - Business/Financial Operations	Form	Unchanged	COVID-19 Patient Impact Module Form - 14MAY2020
241296	COVID-19 Patient Impact Module Form - Business/Financial Operations	Form	Unchanged	COVID-19 Patient Impact Module Form
241296	COVID-19 Patient Impact Module Form - Business/Financial Operations	Instruction	Unchanged
240833	COVID-19 Patient Impact Module Form - Microbiologist	Form	Unchanged	COVID-19 Patient Impact Module Form 29MAY2020
240833	COVID-19 Patient Impact Module Form - Microbiologist	Form	Unchanged	COVID-19 Patient Impact Module Form - 14MAY2020
240833	COVID-19 Patient Impact Module Form - Microbiologist	Form	Unchanged	COVID-19 Patient Impact Module Form
240833	COVID-19 Patient Impact Module Form - Microbiologist	Instruction	Unchanged

ICR Details

OMB Control No: 0920-1290	ICR Reference No: 202006-0920-014
Status: Historical Inactive	Previous ICR Reference No: 202005-0920-014
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1290
Title: National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 03/24/2020
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 07/02/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/01/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2020	09/30/2020	09/30/2020
Responses	3,235,450	0	3,235,450
Time Burden (Hours)	1,206,491	0	1,206,491
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of this information collection is to 1) capture the daily, aggregate impact of COVID-19 on healthcare facilities, and 2) monitor medical capacity to respond at local, state, and national levels. This information will be used to inform the overall real-time COVID-19 response efforts and possible resource allocation, and enable state and local health departments to gain immediate access to the COVID-19 data for hospitals within their jurisdiction. Information collection for long term care facilities are being added to this request. This Change Request will add nine data elements to the Patient Impact and Hospital Capacity form and will add TeleTracking to the NHSN collection at the request the White House Coronavirus Task Force in order to strengthen COVID-19 response efforts.

Emergency Justfication: I have determined that the information must be collected prior to the expiration of time period established under Part 1320, and that this information is essential to CDC’s ability, as well as that of state and local health departments, to effectively address the national public health crisis caused by the Novel Coronavirus (COVID-19). As rates of infection and resulting deaths continue to rise across the nation, healthcare facilities and public health departments are facing significant strain on patient care and infection prevention efforts. NHSN plans to introduce a new surveillance module that will enable hospitals to report daily COVID-19 patient counts to NHSN, and NHSN in turn will enable state and local health departments to gain immediate access to the COVID-19 data for hospitals in their jurisdiction. COVID-19 data submitted to NHSN also will be used immediately by CDC’s emergency COVID-19 response. NHSN’s role as a shared platform for healthcare-associated infection surveillance provides a valuable foundation for COVID-19 surveillance. The COVID-19 modules can additionally be adapted for future outbreaks of COVID or other infectious diseases. A large majority of the nation’s hospitals already participate in NHSN, and infection preventionists (IPs) in those hospitals use NHSN for surveillance and reporting of healthcare-associated infection and antimicrobial resistance. CDC cannot reasonably comply with the normal clearance procedures due to the public harm that could escalate if routine processing of this request is required. CDC requests authorization to use information collection instruments in the existing NHSN web-based application for 180 days to enable immediate CDC and public health departments with immediate access to COVID-19 patient impact data.

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Authorizing Statute(s): US Code: 42 USC 242b, 242k, 242m Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 29

table that charts list of burden

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

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Change Request adds additional 5 minutes of burden to the COVID-19 Hospital Supply Pathway Form

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/01/2020

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