LTCF Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry

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 LTCF Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry 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:	LTCF Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry	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: 5,811	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	5,811	5,811
Annual IC Time Burden (Hours)	4,358	4,358
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.