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 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
No associated records found

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