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Federal forms, ICRs, and supporting documents

Information Collection

Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2

IC 241429 under ICR 202009-0920-021 · OMB 0920-1296.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2 0920-20MZ
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0920-20MZ Assessment of Healthcare Personnel Attachment4_Assessment of healthcare personnel.docx Yes Yes Fillable Fileable
Form and Instruction 0920-1296 Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2 Possible Reinfection Form Attachment 1_Exposure Assessment Form_07_23_2020_CLEAN_after comments from OMB.docx NA Yes Yes Fillable Fileable
Form and Instruction 0920-1296 Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2 Form Attachment 2_Possible Reinfection Form_07_17_2020_CLEAN.docx NA Yes Yes Fillable Fileable
Form and Instruction 0920-1296 Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2 Case/Non-Case 25AUG2020 HCP Case and non_Case_Exposure Assessment Form_8_19_2020.docx NA Yes Yes Fillable Fileable

Health Public Health Monitoring

 

4,000 0
   
Individuals or Households
 
   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 4,000 0 0 0 0 4,000
Annual IC Time Burden (Hours) 2,133 0 0 0 0 2,133
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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