Information Collection

VA - Resident COVID-19 Event Form - LTCF

IC 247668 under ICR 202105-0920-014 · OMB 0920-1317.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1317 VA - Resident COVID-19 Event Form - LTCF	Form
0920-1317 VA COVID-19 Resident Event Form VA Covid-19 Reporting_Resident_v9_13May_CLEAN (004).docx	Form
0920-1317 VA COVID-19 Resident Event Form VA Covid-19 Reporting_Resident_v9_13May_CLEAN (004).docx	Form
VA COVID-19 Resident toi_V7_27April_CLEAN.docx Instructions VA Resident COVID-19 Event Form	IC Document
VA COVID-19 Resident toi_V7_27April_CLEAN.docx Instructions VA Resident COVID-19 Event Form	IC Document

IC Title:

VA - Resident COVID-19 Event Form - LTCF

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-1317	VA COVID-19 Resident Event Form	VA Covid-19 Reporting_Resident_v9_13May_CLEAN (004).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: 188

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,768	6,768
Annual IC Time Burden (Hours)	4,512	4,512
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Instructions VA Resident COVID-19 Event Form	VA COVID-19 Resident toi_V7_27April_CLEAN.docx	05/28/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.