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

Documents and forms in this information collection
Document Name	Document Type
Form 0920-20MZ Assessment of Healthcare Personnel Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2	Form and Instruction
Form 0920-1296 Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2 Possible Reinfection Form Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2	Form and Instruction
Form 0920-1296 Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2 Form Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2	Form and Instruction
Form 0920-1296 Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2 Case/Non-Case 25AUG2020 Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2	Form and Instruction
0920-20MZ Assessment of Healthcare Personnel Attachment4_Assessment of healthcare personnel.docx	Form and Instruction
0920-1296 Assessment of Healthcare Personnel Exposed to or Infecte Attachment 1_Exposure Assessment Form_07_23_2020_CLEAN_after comments from OMB.docx	Form and Instruction
0920-1296 Assessment of Healthcare Personnel Exposed to or Infecte Attachment 2_Possible Reinfection Form_07_17_2020_CLEAN.docx	Form and Instruction
0920-1296 Assessment of Healthcare Personnel Exposed to or Infecte HCP Case and non_Case_Exposure Assessment Form_8_19_2020.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-20MZ

Is this a Common Form? No

IC Status: Modified

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	0920-20MZ	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

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	2,133	2,133
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.