Information Collection Request

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

ICR 202011-0920-005 · OMB 0920-1306 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Dialysis Facility Infection Preventionists - NHSN New Facility Enrollment Form New Available
Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form Form New Available
Form 57.145 State and Local Health Department occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form New Available
Form 57.145 Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form and Instruction New Available
Form 57.145 LTCF - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form New Available
Form 57.145 State and Local Health Department occupations -Staff and Personnel Impact form (57.145) Form New Available
Form 57.145 Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) Form New Available
Form 57.145 LTCF - Staff and Personnel Impact form (57.145) Form New Available
Form 57.144 State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Datat Entry Form New Available
Form 57.144 Business and Financial Operations occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry Form New Available
Form 57.144 LTCF Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry Form New Available
Form 57.144 State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) Form New Available
Form 57.144 Business and Financial Operations Occupations - Resident Impact and Facility Capacity form (57.144) Form New Available
Form 57.144 LTCF Personnel - Resident Impact and Facility Capacity form (57.144) Form New Available
Form 57.155 NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel 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 IDCollectionTypeStatusForm
244456 Dialysis Facility Infection Preventionists - NHSN New Facility Enrollment Form New
244455 Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form Form New
244454 State and Local Health Department occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form New
244453 Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form and Instruction New
244452 LTCF - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form New
244451 State and Local Health Department occupations -Staff and Personnel Impact form (57.145) Form New
244450 Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) Form New
244449 LTCF - Staff and Personnel Impact form (57.145) Form New
244448 State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Datat Entry Form New
244447 Business and Financial Operations occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry Form New
244446 LTCF Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry Form New
244445 State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) Form New
244444 Business and Financial Operations Occupations - Resident Impact and Facility Capacity form (57.144) Form New
244443 LTCF Personnel - Resident Impact and Facility Capacity form (57.144) Form New
244087 NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel Form and Instruction Unchanged

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
11/30/2020 11/30/2020 11/30/2020
3,229,106 0 1,098,200
1,139,032 0 137,275
0 0 0





Reginfo record details
15
table that charts list of burden
IC Title Form No. Form Name
NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel 57.155, 57.155 NHSN - Point of Care Testing Results - LTCF personnel (reporting resident test results) ,   NHSN - Point of Care Testing Results -LTCF personnel (reporting staff test results)
LTCF Personnel - 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) 57.144 Resident Impact and Facility Capacity form (57.144)
State and Local Health Department occupations - 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)
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)
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)
LTCF - 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) 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)
LTCF - Staff and Personnel Impact form (57.145) - Retrospective Data Entry 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
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)

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


Reginfo record details
  No