Supplies & Personal Protective Equipment - LTCF Personnel

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1317 can be found here:

Documents and Forms

Document Name Document Type
Form CDC 57.146 Supplies & Personal Protective Equipment - LTCF Personnel Form and Instruction
CDC 57.146 Supplies & Personal Protective Equipment CDC 57.146_COVID-19 form_Supplies and Personal Protective Equipment_v2 Final.docx Form and Instruction
CDC 57.146 Supplies & Personal Protective Equipment CDC 57.146_COVID-19 form_Supplies and Personal Protective Equipment_v2 Final.docx Form and Instruction
CDC 57.146 COVID-19 Module - LTCF: Supplies and Personal Protective CDC 57.146_PPE_draft_Release 9.5.1.2_V4_revised per ASPR CMS CDC PGL Call clean.docx Form and Instruction
CDC 57.146 COVID-19 Module - LTCF: Supplies and Personal Protective CDC 57.146_PPE_draft_Release 9.5.1.2_V4_revised per ASPR CMS CDC PGL Call clean.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Supplies & Personal Protective Equipment - LTCF Personnel	Agency IC Tracking Number:	0920-20LW

Is this a Common Form? No		IC Status: Unchanged

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 and Instruction	CDC 57.146	Supplies & Personal Protective Equipment	CDC 57.146_COVID-19 form_Supplies and Personal Protective Equipment_v2 Final.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CDC 57.146	COVID-19 Module - LTCF: Supplies and Personal Protective Equipment	CDC 57.146_PPE_draft_Release 9.5.1.2_V4_revised per ASPR CMS CDC PGL Call 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: 11,621	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	Previously Approved
Annual Number of Responses for this IC	604,292	604,292
Annual IC Time Burden (Hours)	251,788	251,788
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.