Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form

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
Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form Form
Dialysis COVID-19 Outpatient Form COVID 19 dialysis outpatient module form CLEAN.docx Form

Information Collection (IC) Details

IC Title:	Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form	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	NA	Dialysis COVID-19 Outpatient Form	COVID 19 dialysis outpatient module form CLEAN.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: 4,900	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	509,600	509,600
Annual IC Time Burden (Hours)	127,400	127,400
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.