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 Fo Healthcare Personnel Safety Monthly Reporting Plan	Form and Instruction	New	Available
Form 0920-1317 / CDC Fo Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities	Form and Instruction	New	Repair queued
Form 0920-1317 / CDC Fo Healthcare Personnel Safety Monthly Reporting Plan	Form and Instruction	New	Available
Form 0920-1317 / CDC Fo Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	Form and Instruction	New	Repair queued
Form 0920-1317 / CDC Fo Monthly Reporting Plan for LTCF	Form and Instruction	New	Available
Form 0920-1317 / CDC Fo Monthly Reporting Plan form for Long-term Care Facilities	Form and Instruction	New	Repair queued
Form 0920-1317 / CDC Fo Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients	Form and Instruction	New	Available
Form 0920-1317 / CDC Fo Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	Form and Instruction	New	Repair queued
Form 0920-1317 / CDC Fo Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities	Form and Instruction	New	Available
Form 0920-1317 / CDC Fo Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	New	Repair queued
Form 0920-1317 / CDC Fo Healthcare Personnel COVID-19 Vaccination Cumulative Summary	Form and Instruction	New	Available
Form 0920-1317 / CDC Fo Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary	Form and Instruction	New	Repair queued
Form 0920-1317 Staff and Personnel COVID-19 Event Form 22SEP2021	Form and Instruction	Modified	Available
Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form	Form	Modified	Available
Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form - LTCF	Form	Modified	Repair queued
Form 0920-1317 Resident COVID-19 Event Form 22SEP2021	Form and Instruction	Modified	Available
Form 0920-1317 VA COVID-19 Resident Event Form	Form	Modified	Available
Form 0920-1317 VA - Resident COVID-19 Event Form - LTCF	Form	Modified	Repair queued
Form 0920-1317 CDC 57.X Long Term Care Facility: Resident Therapeutics	Form and Instruction	Unchanged	Available
Form 0920-1317 CDC 57.X Resident Therapeutics - State and Local Health Dept. Occupations	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 CDC 57.X Long Term Care Facility: Resident Therapeutics	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 CDC 57.X Resident Therapeutics - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 CDC 57.X Long-Term Care Facility: Resident Therapeutics	Form and Instruction	Modified	Available
Form 0920-1317 CDC 57.X Resident Therapeutics - LTCF Personnel	Form and Instruction	Modified	Repair queued
Form 0920-1317 / Form 5 COVID–19 Module - Dialysis Outpatient Facility	Form and Instruction	Modified	Available
Form 0920-1317 COVID-19 Module Dialysis Outpatient Facility Form 27MAY2021	Form and Instruction	Modified	Available
Form 0920-1317 COVID-19 Module Dialysis Outpatient Facility	Form and Instruction	Modified	Available
Form 0920-20LW Dialysis Component	Form and Instruction	Modified	Available
Form 0920-20LW Dialysis Component	Form and Instruction	Modified	Repair queued
Form CDC 57.147 Ventilator Capacity & Supplies	Form and Instruction	Unchanged	Repair queued
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 COVID-19 Module - LTCF: Supplies and Personal Protective Equipment	Form and Instruction	Unchanged	Available
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 COVID-19 Module - LTCF: Supplies and Personal Protective Equipment	Form and Instruction	Unchanged	Available
Form CDC 57.146 Supplies & Personal Protective Equipment	Form and Instruction	Unchanged	Repair queued
Form CDC 57.146 Supplies & Personal Protective Equipment - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Repair queued
Form CDC 57.146 COVID-19 Module - LTCF: Supplies and Personal Protective Equipment	Form and Instruction	Unchanged	Available
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	Available
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	Unchanged	Available
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	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 CDC 57.1 Resident Impact and Facility Capacity	Form and Instruction	Unchanged	Available
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	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 Form 57. Resident Impact and Facility Capacity Form 21SEP2021	Form and Instruction	Modified	Available
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 - LTCF Personnel	Form and Instruction	Modified	Repair queued
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
Change Memo 0920-1317 NHSN COVID SEP22_final.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-09-22	Repair queued
Change Memo for NHSN VHA_tb_lw.tbg3 final.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-05-28	Repair queued
0920-1317 Change Memo - NHSN LTCF PPE_DIALYSIS_TBG.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-02-25	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	Available
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
249439	Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities	Form and Instruction	New	Healthcare Personnel Safety Monthly Reporting Plan
249439	Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities	Form and Instruction	New
249438	Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	Form and Instruction	New	Healthcare Personnel Safety Monthly Reporting Plan
249438	Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	Form and Instruction	New
249437	Monthly Reporting Plan form for Long-term Care Facilities	Form and Instruction	New	Monthly Reporting Plan for LTCF
249437	Monthly Reporting Plan form for Long-term Care Facilities	Form and Instruction	New
249436	Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	Form and Instruction	New	Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients
249436	Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	Form and Instruction	New
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	New	Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	New
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary	Form and Instruction	New	Healthcare Personnel COVID-19 Vaccination Cumulative Summary
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary	Form and Instruction	New
247669	VA - Staff and Personnel COVID-19 Event Form - LTCF	Form and Instruction	Modified	Staff and Personnel COVID-19 Event Form 22SEP2021
247669	VA - Staff and Personnel COVID-19 Event Form - LTCF	Form	Modified	VA - Staff and Personnel COVID-19 Event Form
247669	VA - Staff and Personnel COVID-19 Event Form - LTCF	Form	Modified
247668	VA - Resident COVID-19 Event Form - LTCF	Form and Instruction	Modified	Resident COVID-19 Event Form 22SEP2021
247668	VA - Resident COVID-19 Event Form - LTCF	Form	Modified	VA COVID-19 Resident Event Form
247668	VA - Resident COVID-19 Event Form - LTCF	Form	Modified
245466	Resident Therapeutics - State and Local Health Dept. Occupations	Form and Instruction	Unchanged	Long Term Care Facility: Resident Therapeutics
245466	Resident Therapeutics - State and Local Health Dept. Occupations	Form and Instruction	Unchanged
245464	Resident Therapeutics - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Long Term Care Facility: Resident Therapeutics
245464	Resident Therapeutics - Business and Financial Operations Occupations	Form and Instruction	Unchanged
245463	Resident Therapeutics - LTCF Personnel	Form and Instruction	Modified	Long-Term Care Facility: Resident Therapeutics
245463	Resident Therapeutics - LTCF Personnel	Form and Instruction	Modified
243719	Dialysis Component	Form and Instruction	Modified	COVID–19 Module - Dialysis Outpatient Facility
243719	Dialysis Component	Form and Instruction	Modified	COVID-19 Module Dialysis Outpatient Facility Form 27MAY2021
243719	Dialysis Component	Form and Instruction	Modified	COVID-19 Module Dialysis Outpatient Facility
243719	Dialysis Component	Form and Instruction	Modified	Dialysis Component
243719	Dialysis Component	Form and Instruction	Modified
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	COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
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	COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
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	COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
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	Unchanged	Resident Impact and Facility Capacity
243701	Resident Impact and Facility Capacity - State and Local Health Dept Occupations	Form and Instruction	Unchanged	Resident Impact and Facility Capacity
243701	Resident Impact and Facility Capacity - State and Local Health Dept Occupations	Form and Instruction	Unchanged
243700	Resident Impact and Facility Capacity - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Resident Impact and Facility Capacity
243700	Resident Impact and Facility Capacity - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Resident Impact and Facility Capacity
243700	Resident Impact and Facility Capacity - Business and Financial Operations Occupations	Form and Instruction	Unchanged
243699	Resident Impact and Facility Capacity - LTCF Personnel	Form and Instruction	Modified	Resident Impact and Facility Capacity Form 21SEP2021
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	Resident Impact and Facility Capacity
243699	Resident Impact and Facility Capacity - LTCF Personnel	Form and Instruction	Modified
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: 202109-0920-006
Status: Historical Active	Previous ICR Reference No: 202105-0920-014
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1317-21IH
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: 10/07/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/22/2021
Terms of Clearance: Previous terms continue: 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	7,502,054	0	5,052,366
Time Burden (Hours)	4,736,898	0	1,732,245
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 improve the usefulness and quality of data that is gathered regarding residents with newly positive SARS-CoV-2 viral test results and their vaccination status. This will also likely aid in improving the quality of data which can be used regarding break-through cases.

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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: 31

table that charts list of burden

IC Title	Form No.	Form Name
Dialysis Component	0920-20LW, 0920-1317, 0920-1317, 0920-1317 / Form 57.510	Dialysis Component ,   COVID-19 Module Dialysis Outpatient Facility ,   COVID-19 Module Dialysis Outpatient Facility Form 27MAY2021 ,   COVID–19 Module - Dialysis Outpatient Facility
Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	0920-1317 / CDC Form 57.203	Healthcare Personnel Safety Monthly Reporting Plan
Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities	0920-1317 / CDC Form 57.203	Healthcare Personnel Safety Monthly Reporting Plan
Monthly Reporting Plan form for Long-term Care Facilities	0920-1317 / CDC Form 57.141	Monthly Reporting Plan for LTCF
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 Form 57.144, 0920-1317 CDC 57.144, CDC 57.144	Resident Impact and Facility Capacity ,   Resident Impact and Facility Capacity ,   Resident Impact and Facility Capacity Form 21SEP2021
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, CDC 57.146	Supplies & Personal Protective Equipment ,   COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
Supplies & Personal Protective Equipment - LTCF Personnel	CDC 57.146, CDC 57.146	Supplies & Personal Protective Equipment ,   COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
Supplies & Personal Protective Equipment - State and Local Health Dept Occupations	CDC 57.146, CDC 57.146	Supplies & Personal Protective Equipment ,   COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
VA - Resident COVID-19 Event Form - LTCF	0920-1317, 0920-1317	VA COVID-19 Resident Event Form ,   Resident COVID-19 Event Form 22SEP2021
VA - Staff and Personnel COVID-19 Event Form - LTCF	0920-1317, 0920-1317	VA - Staff and Personnel COVID-19 Event Form ,   Staff and Personnel COVID-19 Event Form 22SEP2021
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
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary	0920-1317 / CDC Form 57.219	Healthcare Personnel COVID-19 Vaccination Cumulative Summary
Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	0920-1317 / CDC Form 57.509	Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities	0920-1317 / CDC Form 57.218	Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities

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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	7,502,054	5,052,366	0	2,449,688	0	0
Annual Time Burden (Hours)	4,736,898	1,732,245	0	3,004,653	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden change due to modifications made to the following 0920-1317 Forms: 1. Dialysis COVID-19 form (57.510) 2. LTCF Veterans Affairs Staff and Personnel COVID-19 Event form (57.160) 3. LTCF Veterans Affairs Resident COVID-19 Event form (57.159) 4. LTCF Point of Care Testing Results Tool (57.155) 5. LTCF Resident Impact and Facility Capacity form (57.144) 6. LTCF healthcare associated infections event form (57.142) 7. Weekly COVID-19 Vaccination Data Collection Forms & Monthly Reporting Plans: 57.203, 57.141, 57.509, 57.219, 57.218

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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: 09/22/2021

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