Information Collection

Occupational Health Nurses at Healthcare Facilities -Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2: Denominator Form

IC 242771 under ICR 202009-0920-021 · OMB 0920-1296.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1296 Occupational Health Nurses at Healthcare Facilities -Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2: Denominator Form	Form and Instruction
0920-1296 Assessment of Healthcare Personnel Exposed to or Infecte Attachment 3_Denominator Form_07_17_2020_CLEAN.docx	Form and Instruction
0920-1296 Assessment of Healthcare Personnel Exposed to or Infecte Att 3_HCP Exposed_Infected with SARS-CoV-2_Denominator Form.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

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	0920-1296	Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2: Denominator Form	Attachment 3_Denominator 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 06OCT2020	Att 3_HCP Exposed_Infected with SARS-CoV-2_Denominator Form.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: 50

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	100	100
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.