COVID-19 Supplies Form - State and Local Health Department

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⚠️ Notice: This information collection may be referencing outdated material.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
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 01JUL2020 57.132_v2cCOVID-19_SUP 06122020 FINAL.docx Form and Instruction
TOI_57.132_v2bCOVI-19 SUP_06122020 Final .docx Instructions - Hospital Supply Pathway Form IC Document

Information Collection (IC) Details

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:

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 01JUL2020	57.132_v2cCOVID-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 %

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

Documents for IC

Title	Document	Date Uploaded
Instructions - Hospital Supply Pathway Form	TOI_57.132_v2bCOVI-19 SUP_06122020 Final .docx	07/01/2020

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