Information Collection

State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry

IC 241807 under ICR 202007-0920-017 · 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⚠️ Notice: This information collection may be referencing outdated material.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 State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry	Form and Instruction
0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form ( CDC 57.145_TOI_Staff and Personnel Impact lw CLEAN.docx	Form and Instruction

IC Title:

State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry

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 and Instruction	0920-1290	COVID-19 Module - LTCF Staff and Personnel Impact Form (Retrospective Datat Entry)	CDC 57.145_TOI_Staff and Personnel Impact lw CLEAN.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: 1,223

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	1,223	1,223
Annual IC Time Burden (Hours)	306	306
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.