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

Emergency Extension - National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.