State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144)

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

Documents and Forms

Document Name Document Type
Form 57.144 State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) Form
57.144 Resident Impact and Facility Capacity form (57.144) 57.144-RIFC Form_V5_OMB Submission CLEAN__10.30.20.docx Form

Information Collection (IC) Details

IC Title:	State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144)	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	57.144	Resident Impact and Facility Capacity form (57.144)	57.144-RIFC Form_V5_OMB Submission CLEAN__10.30.20.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: 1,870	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	97,240	97,240
Annual IC Time Burden (Hours)	72,930	72,930
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.