Information Collection

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

IC 241297 under ICR 202007-0920-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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: 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	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 - 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
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

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	93,420	93,420
Annual IC Time Burden (Hours)	62,280	62,280
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.