Occupational Health Nurses at Healthcare Facilities -Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2: Denominator Form

Emerging Infections Program Tracking of SARS-CoV-2 Infections among Healthcare Personnel

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1296 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1296 Occupational Health Nurses at Healthcare Facilities -Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2: Denominator Form Form and Instruction
0920-1296 Assessment of Healthcare Personnel Exposed to or Infecte Attachment 3_Denominator Form_07_17_2020_CLEAN.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Occupational Health Nurses at Healthcare Facilities -Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2: Denominator Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	0920-1296	Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2: Denominator Form	Attachment 3_Denominator Form_07_17_2020_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: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.