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

IC 241297 under ICR 202008-0920-012 · OMB 0920-1290.

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COVID-19 Patient Impact Module Form - State and Local Health Departments
 
No Unchanged
 
Voluntary
 

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

Health Public Health Monitoring

 

519 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 93,420 0 0 0 0 93,420
Annual IC Time Burden (Hours) 62,280 0 0 0 0 62,280
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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