Information Collection

NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel

IC 244087 under ICR 202010-0920-008 · OMB 0920-1306.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1306 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.155 NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel	Form and Instruction
57.155 NHSN - Point of Care Testing Results -LTCF personnel (re 57.XXX_Point of Care Testing Final 10 15 20.docx	Form and Instruction
57.155 NHSN - Point of Care Testing Results - LTCF personnel (r 57.XXX_Point of Care Testing Final 10 15 20.docx	Form and Instruction
57.155 Table of Instructions for Point of Care Testing (POC) Form 10 15 20.docx Instructions - POC Form	IC Document

IC Title:

NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	57.155	NHSN - Point of Care Testing Results -LTCF personnel (reporting staff test results)	57.XXX_Point of Care Testing Final 10 15 20.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	57.155	NHSN - Point of Care Testing Results - LTCF personnel (reporting resident test results)	57.XXX_Point of Care Testing Final 10 15 20.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: 6,800

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,098,200	1,098,200
Annual IC Time Burden (Hours)	137,275	137,275
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Instructions - POC Form	57.155 Table of Instructions for Point of Care Testing (POC) Form 10 15 20.docx	10/15/2020

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