LTC Supplies and PPE - state/local health depts.

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

Documents and Forms

Document Name Document Type
LTC Supplies and PPE - state/local health depts. Form
LTC Supplies and PPE LTC_SUPPLIESv2 042320.docx Form

Information Collection (IC) Details

IC Title:	LTC Supplies and PPE - state/local health depts.	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	LTC Supplies and PPE	LTC_SUPPLIESv2 042320.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,446	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	63,596	63,596
Annual IC Time Burden (Hours)	15,899	15,899
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.