LTCF Resident Impact and Facility Capacity - LTCF personnel

National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities

Documents and Forms

Document Name Document Type
LTCF Resident Impact and Facility Capacity - LTCF personnel Form
Resident impact and facility capacity CDC 57.144_COVID-19 form_Resident Impact and Facility Capacity_v3_Ready for DEV 7.23.20.docx Form
0920-1290 LTCF Resident Impact and Facitlity Capacity POC - 26AUG2 CDC 57.144_COVID-19_Resident Impact and Facility Capacity POC 20AUG2020.docx Form and Instruction
CDC 57.144_TOI_Resident Impact and Facility Capacity POC 20AUG2020.docx Instructions - LTCF Resident Impact and Facitlity Capacity IC Document

Information Collection (IC) Details

IC Title:	LTCF Resident Impact and Facility Capacity - LTCF personnel	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	none	Resident impact and facility capacity	CDC 57.144_COVID-19 form_Resident Impact and Facility Capacity_v3_Ready for DEV 7.23.20.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1290	LTCF Resident Impact and Facitlity Capacity POC - 26AUG2020	CDC 57.144_COVID-19_Resident Impact and Facility Capacity POC 20AUG2020.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: 9,782	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	254,332	0	254,332
Annual IC Time Burden (Hours)	169,555	21,195	148,360
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Instructions - LTCF Resident Impact and Facitlity Capacity	CDC 57.144_TOI_Resident Impact and Facility Capacity POC 20AUG2020.docx	08/26/2020

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