Information Collection

COVID-19 Supplies Form - State and Local Health Department

IC 241303 under ICR 202006-0920-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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 COVID-19 Supplies Form - State and Local Health Department	Form and Instruction
0920-1290 COVID-19 Supplies Form Att8_NHSN COVID-19 Supplies Form .docx	Form and Instruction
0920-1290 COVID-19 Module - Hospital Supply Pathway 19JUN2020 57.132_COVID-19_SUP 06122020 Final.docx	Form and Instruction
TOI_57.132_v2aCOVI-19 SUP_06122020 Final .docx COVID-19 - Hospital Supply Pathway Form - Instructions	IC Document

IC Title:

COVID-19 Supplies Form - State and Local Health Department

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 and Instruction	0920-1290	COVID-19 Supplies Form	Att8_NHSN COVID-19 Supplies Form .docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1290	COVID-19 Module - Hospital Supply Pathway 19JUN2020	57.132_COVID-19_SUP 06122020 Final.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: 519

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
	Requested	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)	46,710	7,785	38,925
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
COVID-19 - Hospital Supply Pathway Form - Instructions	TOI_57.132_v2aCOVI-19 SUP_06122020 Final .docx	06/22/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.