National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1317 CDC 57.X Long Term Care Facility: Resident Therapeutics	Form and Instruction	New	Available
Form 0920-1317 CDC 57.X Resident Therapeutics - State and Local Health Dept. Occupations	Form and Instruction	New	Repair queued
Form 0920-1317 CDC 57.X Long Term Care Facility: Resident Therapeutics	Form and Instruction	New	Available
Form 0920-1317 CDC 57.X Resident Therapeutics - Business and Financial Operations Occupations	Form and Instruction	New	Repair queued
Form 0920-1317 CDC 57.X Long-Term Care Facility: Resident Therapeutics	Form and Instruction	New	Available
Form 0920-1317 CDC 57.X Resident Therapeutics - LTCF Personnel	Form and Instruction	New	Repair queued
Form 0920-20LW Dialysis Component	Form and Instruction	Unchanged	Available
Form 0920-20LW Dialysis Component	Form and Instruction	Unchanged	Repair queued
Form CDC 57.147 Ventilator Capacity & Supplies	Form and Instruction	Unchanged	Available
Form CDC 57.147 Ventilator Capacity & Supplies - State and Local Health Dept Occupations	Form and Instruction	Unchanged	Repair queued
Form CDC 57.147 Ventilator Capacity & Supplies	Form and Instruction	Unchanged	Available
Form CDC 57.147 Ventilator Capacity & Supplies - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Repair queued
Form CDC 57.147 Ventilator Capacity & Supplies	Form and Instruction	Unchanged	Available
Form CDC 57.147 Ventilator Capacity & Supplies - LCTF Personnel	Form and Instruction	Unchanged	Repair queued
Form CDC 57.146 Supplies & Personal Protective Equipment	Form and Instruction	Unchanged	Available
Form CDC 57.146 Supplies & Personal Protective Equipment - State and Local Health Dept Occupations	Form and Instruction	Unchanged	Repair queued
Form CDC 57.146 Supplies & Personal Protective Equipment	Form and Instruction	Unchanged	Available
Form CDC 57.146 Supplies & Personal Protective Equipment - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Repair queued
Form CDC 57.146 Supplies & Personal Protective Equipment	Form and Instruction	Unchanged	Available
Form CDC 57.146 Supplies & Personal Protective Equipment - LTCF Personnel	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations retrospective	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations retrospective	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel retrospective	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel	Form and Instruction	Unchanged	Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity	Form and Instruction	Unchanged	Available
Form CDC 57.144 Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective	Form and Instruction	Unchanged	Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity	Form and Instruction	Unchanged	Available
Form CDC 57.144 Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective	Form and Instruction	Unchanged	Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity	Form and Instruction	Unchanged	Available
Form CDC 57.144 Resident Impact and Facility Capacity - LTCF Personnel retrospective	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 CDC 57.1 Resident Impact and Facility Capacity	Form and Instruction	Modified	Available
Form CDC 57.144 Resident Impact and Facility Capacity	Form and Instruction	Modified	Available
Form CDC 57.144 Resident Impact and Facility Capacity - State and Local Health Dept Occupations	Form and Instruction	Modified	Repair queued
Form 0920-1317 CDC 57.1 Resident Impact and Facility Capacity	Form and Instruction	Modified	Available
Form CDC 57.144 Resident Impact and Facility Capacity	Form and Instruction	Modified	Available
Form CDC 57.144 Resident Impact and Facility Capacity - Business and Financial Operations Occupations	Form and Instruction	Modified	Repair queued
Form 0920-1317 CDC 57.1 Resident Impact and Facility Capacity	Form and Instruction	Modified	Available
Form 0920-1317 CDC 57.1 Resident Impact and Facility Capacity - LTCF Personnel	Form and Instruction	Modified	Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity	Form and Instruction	Modified	Available
Form 0920-20LW NHSN Registration Form	Form and Instruction	Unchanged	Available
Form 0920-20LW NHSN and Secure Access Management Services (SAMS) enrollment	Form and Instruction	Unchanged	Repair queued
NHSN COVID Module Non-sub change request 012621.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-01-28	Repair queued
Att6_NHSN Report of End of Human Research Review.docx	Supplementary Document	Uploaded 2020-09-21	Repair queued
Att5_Closure of CDC Protocol 4062.docx	Supplementary Document	Uploaded 2020-09-21	Repair queued
Att4_How to Enter and Access COVID Summary Data.docx	Supplementary Document	Uploaded 2020-09-21	Repair queued
Att3_PIA.pdf	Supplementary Document	Uploaded 2020-09-21	Repair queued
Att2_60 Day FRN.pdf	Supplementary Document	Uploaded 2020-09-21	Repair queued
Att1c_42 USC 242m.pdf	Supplementary Document	Uploaded 2020-09-21	Repair queued
Att1b_42 USC 242k.pdf	Supplementary Document	Uploaded 2020-09-21	Repair queued
Att1a_42 USC 242b.pdf	Supplementary Document	Uploaded 2020-09-21	Repair queued
Supporting Statement B NHSN COVID-19_clean.09.01.20 .docx	Supporting Statement B	Uploaded 2020-09-21	Repair queued
NHSN COVID SSA_15JAN2021.docx	Supporting Statement A	Uploaded 2021-01-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
245466	Resident Therapeutics - State and Local Health Dept. Occupations	Form and Instruction	New	Long Term Care Facility: Resident Therapeutics
245466	Resident Therapeutics - State and Local Health Dept. Occupations	Form and Instruction	New
245464	Resident Therapeutics - Business and Financial Operations Occupations	Form and Instruction	New	Long Term Care Facility: Resident Therapeutics
245464	Resident Therapeutics - Business and Financial Operations Occupations	Form and Instruction	New
245463	Resident Therapeutics - LTCF Personnel	Form and Instruction	New	Long-Term Care Facility: Resident Therapeutics
245463	Resident Therapeutics - LTCF Personnel	Form and Instruction	New
243719	Dialysis Component	Form and Instruction	Unchanged	Dialysis Component
243719	Dialysis Component	Form and Instruction	Unchanged
243718	Ventilator Capacity & Supplies - State and Local Health Dept Occupations	Form and Instruction	Unchanged	Ventilator Capacity & Supplies
243718	Ventilator Capacity & Supplies - State and Local Health Dept Occupations	Form and Instruction	Unchanged
243717	Ventilator Capacity & Supplies - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Ventilator Capacity & Supplies
243717	Ventilator Capacity & Supplies - Business and Financial Operations Occupations	Form and Instruction	Unchanged
243716	Ventilator Capacity & Supplies - LCTF Personnel	Form and Instruction	Unchanged	Ventilator Capacity & Supplies
243716	Ventilator Capacity & Supplies - LCTF Personnel	Form and Instruction	Unchanged
243714	Supplies & Personal Protective Equipment - State and Local Health Dept Occupations	Form and Instruction	Unchanged	Supplies & Personal Protective Equipment
243714	Supplies & Personal Protective Equipment - State and Local Health Dept Occupations	Form and Instruction	Unchanged
243713	Supplies & Personal Protective Equipment - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Supplies & Personal Protective Equipment
243713	Supplies & Personal Protective Equipment - Business and Financial Operations Occupations	Form and Instruction	Unchanged
243712	Supplies & Personal Protective Equipment - LTCF Personnel	Form and Instruction	Unchanged	Supplies & Personal Protective Equipment
243712	Supplies & Personal Protective Equipment - LTCF Personnel	Form and Instruction	Unchanged
243711	Staff and Personnel Impact - State and Local Health Dept Occupations retrospective	Form and Instruction	Unchanged	Staff and Personnel Impact
243711	Staff and Personnel Impact - State and Local Health Dept Occupations retrospective	Form and Instruction	Unchanged
243710	Staff and Personnel Impact - Business and Financial Operations Occupations retrospective	Form and Instruction	Unchanged	Staff and Personnel Impact
243710	Staff and Personnel Impact - Business and Financial Operations Occupations retrospective	Form and Instruction	Unchanged
243709	Staff and Personnel Impact - LTCF Personnel retrospective	Form and Instruction	Unchanged	Staff and Personnel Impact
243709	Staff and Personnel Impact - LTCF Personnel retrospective	Form and Instruction	Unchanged
243708	Staff and Personnel Impact - State and Local Health Dept Occupations	Form and Instruction	Unchanged	Staff and Personnel Impact
243708	Staff and Personnel Impact - State and Local Health Dept Occupations	Form and Instruction	Unchanged
243707	Staff and Personnel Impact - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Staff and Personnel Impact
243707	Staff and Personnel Impact - Business and Financial Operations Occupations	Form and Instruction	Unchanged
243706	Staff and Personnel Impact - LTCF Personnel	Form and Instruction	Unchanged	Staff and Personnel Impact
243706	Staff and Personnel Impact - LTCF Personnel	Form and Instruction	Unchanged
243704	Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective	Form and Instruction	Unchanged	Resident Impact and Facility Capacity
243704	Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective	Form and Instruction	Unchanged
243703	Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective	Form and Instruction	Unchanged	Resident Impact and Facility Capacity
243703	Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective	Form and Instruction	Unchanged
243702	Resident Impact and Facility Capacity - LTCF Personnel retrospective	Form and Instruction	Unchanged	Resident Impact and Facility Capacity
243702	Resident Impact and Facility Capacity - LTCF Personnel retrospective	Form and Instruction	Unchanged
243701	Resident Impact and Facility Capacity - State and Local Health Dept Occupations	Form and Instruction	Modified	Resident Impact and Facility Capacity
243701	Resident Impact and Facility Capacity - State and Local Health Dept Occupations	Form and Instruction	Modified	Resident Impact and Facility Capacity
243701	Resident Impact and Facility Capacity - State and Local Health Dept Occupations	Form and Instruction	Modified
243700	Resident Impact and Facility Capacity - Business and Financial Operations Occupations	Form and Instruction	Modified	Resident Impact and Facility Capacity
243700	Resident Impact and Facility Capacity - Business and Financial Operations Occupations	Form and Instruction	Modified	Resident Impact and Facility Capacity
243700	Resident Impact and Facility Capacity - Business and Financial Operations Occupations	Form and Instruction	Modified
243699	Resident Impact and Facility Capacity - LTCF Personnel	Form and Instruction	Modified	Resident Impact and Facility Capacity
243699	Resident Impact and Facility Capacity - LTCF Personnel	Form and Instruction	Modified
243699	Resident Impact and Facility Capacity - LTCF Personnel	Form and Instruction	Modified	Resident Impact and Facility Capacity
243698	NHSN and Secure Access Management Services (SAMS) enrollment	Form and Instruction	Unchanged	NHSN Registration Form
243698	NHSN and Secure Access Management Services (SAMS) enrollment	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-1317	ICR Reference No: 202101-0920-017
Status: Historical Active	Previous ICR Reference No: 202009-0920-011
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1317-21CP
Title: National Healthcare Safety Network (NHSN) 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: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/01/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/28/2021
Terms of Clearance: CDC will work with its OIRA desk officer should changes due to the changing nature of the public health emergency be necessary. CDC will detail in all publications and use of the data any limitations based upon changes in respondent characteristics.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2024	01/31/2024	01/31/2024
Responses	4,530,322	0	3,731,550
Time Burden (Hours)	1,386,566	0	1,186,873
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 healthcare facilities within their jurisdiction. This Non-Substantive Change Request is submitted to evaluate COVID-19 vaccine effectiveness or impact for a resident with newly positive COVID-19 viral test result. Modifications have been made to the COVID-19 Module, Resident Impact and Facility Capacity form, and a new form COVID-19 Module, Long Term Care Facility: Resident Therapeutics is added to the approved package.

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Authorizing Statute(s): US Code: 42 USC 242b, k, m Name of Law: The Public Health Service Act
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 21443	04/17/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 59313	09/21/2020
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 23

table that charts list of burden

IC Title	Form No.	Form Name
Dialysis Component	0920-20LW	Dialysis Component
NHSN and Secure Access Management Services (SAMS) enrollment	0920-20LW	NHSN Registration Form
Resident Impact and Facility Capacity - Business and Financial Operations Occupations	0920-1317 CDC 57.144, CDC 57.144	Resident Impact and Facility Capacity ,   Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective	CDC 57.144	Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - LTCF Personnel	0920-1317 CDC 57.144, CDC 57.144	Resident Impact and Facility Capacity ,   Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - LTCF Personnel retrospective	CDC 57.144	Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - State and Local Health Dept Occupations	0920-1317 CDC 57.144, CDC 57.144	Resident Impact and Facility Capacity ,   Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective	CDC 57.144	Resident Impact and Facility Capacity
Resident Therapeutics - Business and Financial Operations Occupations	0920-1317 CDC 57.XXX	Long Term Care Facility: Resident Therapeutics
Resident Therapeutics - LTCF Personnel	0920-1317 CDC 57.XXX	Long-Term Care Facility: Resident Therapeutics
Resident Therapeutics - State and Local Health Dept. Occupations	0920-1317 CDC 57.XXX	Long Term Care Facility: Resident Therapeutics
Staff and Personnel Impact - Business and Financial Operations Occupations	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - Business and Financial Operations Occupations retrospective	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel retrospective	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations retrospective	CDC 57.145	Staff and Personnel Impact
Supplies & Personal Protective Equipment - Business and Financial Operations Occupations	CDC 57.146	Supplies & Personal Protective Equipment
Supplies & Personal Protective Equipment - LTCF Personnel	CDC 57.146	Supplies & Personal Protective Equipment
Supplies & Personal Protective Equipment - State and Local Health Dept Occupations	CDC 57.146	Supplies & Personal Protective Equipment
Ventilator Capacity & Supplies - Business and Financial Operations Occupations	CDC 57.147	Ventilator Capacity & Supplies
Ventilator Capacity & Supplies - LCTF Personnel	CDC 57.147	Ventilator Capacity & Supplies
Ventilator Capacity & Supplies - State and Local Health Dept Occupations	CDC 57.147	Ventilator Capacity & Supplies

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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	4,530,322	3,731,550	0	798,772	0	0
Annual Time Burden (Hours)	1,386,566	1,186,873	0	199,693	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: Burden increase due to modifications made to Resident Impact Facility Capacity Form and addition of Resident Therapeutics Form.

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Annual Cost to Federal Government: $0

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: 01/28/2021

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