VA - Resident COVID-19 Event Form - LTCF

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

OMB: 0920-1317

IC ID: 247668

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VA - Resident COVID-19 Event Form - LTCF
 
No Modified
 
Mandatory
 

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
Form and Instruction 0920-1317 Resident COVID-19 Event Form 22SEP2021 VA COVID Reporting RESIDENT Vax.docx NA Yes Yes Fillable Fileable

Health Public Health Monitoring

 

188 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 6,768 0 0 0 0 6,768
Annual IC Time Burden (Hours) 4,512 0 0 0 0 4,512
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Instructions VA Resident COVID-19 Event Form VA COVID-19 Resident toi_V7_27April_CLEAN.docx 05/28/2021
Instructions Resident COVID-19 Event Form 22SEP2021 SVH COVID-19 Resident toi_V8_27April_FINAL.docx 09/22/2021
Instructions for Point of Care Testing Form (CDC 57.155) 57.155 Table of Instructions for Point of Care Testing (POC) Form 9.5.5_FINAL.docx 09/22/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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