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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
NHSN Registration Form	Form	New	Available
Dialysis COVID-19 Outpatient Form	Form	New	Available
Form 57.145 Staff and Personnel Impact form (57.145)	Form	New	Available
Form 57.145 Staff and Personnel Impact form (57.145)	Form and Instruction	New	Available
Form 57.145 Staff and Personnel Impact form (57.145)	Form	New	Available
Form 57.145 Staff and Personnel Impact form (57.145)	Form	New	Available
Form 57.145 Staff and Personnel Impact form (57.145)	Form	New	Available
Form 57.145 Staff and Personnel Impact form (57.145)	Form	New	Available
Form 57.144 Resident Impact and Facility Capacity form (57.144)	Form	New	Available
Form 57.144 Resident Impact and Facility Capacity form (57.144)	Form	New	Available
Form 57.144 Resident Impact and Facility Capacity form (57.144)	Form	New	Available
Form 57.144 Resident Impact and Facility Capacity form (57.144)	Form	New	Available
Form 57.144 Resident Impact and Facility Capacity form (57.144)	Form	New	Available
Form 57.144 Resident Impact and Facility Capacity form (57.144)	Form	New	Available
Form 57.155 NHSN - Point of Care Testing Results - LTCF personnel (reporting resident test results)	Form and Instruction	Unchanged	Available
Form 57.155 NHSN - Point of Care Testing Results -LTCF personnel (reporting staff test results)	Form and Instruction	Unchanged	Available
0920-1306 Change Memo - NHSN COVID-19 LTCF_11.10.20.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-11-11	Available
0920-1290 Change Memo - NHSN COVID-19 LTCF_10 15 20.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-10-15	Available
Revised SSB 15OCT2020.docx	Supporting Statement B	Uploaded 2020-10-15	Available
Revised SSA 15OCT2020.docx	Supporting Statement A	Uploaded 2020-10-15	Available
Revised Emergency Request Memo 15OCT2020.docx	Supplementary Document	Uploaded 2020-10-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
244456	Dialysis Facility Infection Preventionists - NHSN New Facility Enrollment	Form	New	NHSN Registration Form
244455	Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form	Form	New	Dialysis COVID-19 Outpatient Form
244454	State and Local Health Department occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	Form	New	Staff and Personnel Impact form (57.145)
244453	Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	Form and Instruction	New	Staff and Personnel Impact form (57.145)
244452	LTCF - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	Form	New	Staff and Personnel Impact form (57.145)
244451	State and Local Health Department occupations -Staff and Personnel Impact form (57.145)	Form	New	Staff and Personnel Impact form (57.145)
244450	Business and Financial Operations occupations - Staff and Personnel Impact form (57.145)	Form	New	Staff and Personnel Impact form (57.145)
244449	LTCF - Staff and Personnel Impact form (57.145)	Form	New	Staff and Personnel Impact form (57.145)
244448	State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Datat Entry	Form	New	Resident Impact and Facility Capacity form (57.144)
244447	Business and Financial Operations occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry	Form	New	Resident Impact and Facility Capacity form (57.144)
244446	LTCF Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry	Form	New	Resident Impact and Facility Capacity form (57.144)
244445	State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144)	Form	New	Resident Impact and Facility Capacity form (57.144)
244444	Business and Financial Operations Occupations - Resident Impact and Facility Capacity form (57.144)	Form	New	Resident Impact and Facility Capacity form (57.144)
244443	LTCF Personnel - Resident Impact and Facility Capacity form (57.144)	Form	New	Resident Impact and Facility Capacity form (57.144)
244087	NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel	Form and Instruction	Unchanged	NHSN - Point of Care Testing Results - LTCF personnel (reporting resident test results)
244087	NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel	Form and Instruction	Unchanged	NHSN - Point of Care Testing Results -LTCF personnel (reporting staff test results)

ICR Details

OMB Control No: 0920-1306	ICR Reference No: 202011-0920-005
Status: Historical Active	Previous ICR Reference No: 202010-0920-008
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1306
Title: Emergency Extension - National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 10/15/2020
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/18/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/11/2020
Terms of Clearance: Previous terms continue: CDC will commit to evaluating responses and updating associated burdens when this emergency is transitioned into the larger NHSN COVID package.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2020	11/30/2020	11/30/2020
Responses	3,229,106	0	1,098,200
Time Burden (Hours)	1,139,032	0	137,275
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of this information collection is to 1) capture the daily, aggregate impact of COVID-19 on healthcare facilities, and 2) monitor medical capacity to respond at local, state, and national levels. This information will be used to inform the overall real-time COVID-19 response efforts and possible resource allocation, and enable state and local Health Departments to gain immediate access to the COVID-19 data for hospitals within their jurisdictions. This Non-Substantive Change Request is submitted for LTCF forms that have been modified to account for current practices in testing and identifying cases among staff and residents.

Emergency Justfication: CDC seeks a one-month extension of the expired 0920-1290 - National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities package, so that it can incorporate a new data collection form to the NHSN COVID-19 Long Term Care Facility (LTCF) Module: Point of Care Testing Results form (CDC 57.1) The data collected via this form will inform state and local health departments as well as federal public health entities about testing results for patients and staff in nursing homes. This data will be used to identify COVID-19 outbreaks in nursing homes, add to the situational awareness of COVID-19 in jurisdictions, as well as to enable public health agencies to assist in infection prevention and control activities. NHSN has requested OMB approval of this form by 10/15/2020. In order for this nonmaterial/non-substantive change request to be approved, an emergency request to extend the National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities package (0920-1290), is hereby submitted. The changes made as the result of this nonmaterial/non-substantive change request will be incorporated into the standard package upon approval by OMB.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: U.S. PHSA
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Business and Financial Operations Occupations - Resident Impact and Facility Capacity form (57.144)	57.144	Resident Impact and Facility Capacity form (57.144)
Business and Financial Operations occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry	57.144	Resident Impact and Facility Capacity form (57.144)
Business and Financial Operations occupations - Staff and Personnel Impact form (57.145)	57.145	Staff and Personnel Impact form (57.145)
Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	57.145	Staff and Personnel Impact form (57.145)
Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form	NA	Dialysis COVID-19 Outpatient Form
Dialysis Facility Infection Preventionists - NHSN New Facility Enrollment	NA	NHSN Registration Form
LTCF - Staff and Personnel Impact form (57.145)	57.145	Staff and Personnel Impact form (57.145)
LTCF - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	57.145	Staff and Personnel Impact form (57.145)
LTCF Personnel - Resident Impact and Facility Capacity form (57.144)	57.144	Resident Impact and Facility Capacity form (57.144)
LTCF Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry	57.144	Resident Impact and Facility Capacity form (57.144)
NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel	57.155, 57.155	NHSN - Point of Care Testing Results -LTCF personnel (reporting staff test results) ,   NHSN - Point of Care Testing Results - LTCF personnel (reporting resident test results)
State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144)	57.144	Resident Impact and Facility Capacity form (57.144)
State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Datat Entry	57.144	Resident Impact and Facility Capacity form (57.144)
State and Local Health Department occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	57.145	Staff and Personnel Impact form (57.145)
State and Local Health Department occupations -Staff and Personnel Impact form (57.145)	57.145	Staff and Personnel Impact form (57.145)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,229,106	1,098,200	0	2,130,906	0	0
Annual Time Burden (Hours)	1,139,032	137,275	0	1,001,757	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Change Request results in an Increase in burden due to modifications to LTCF forms

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/11/2020

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