Information Collection

VA - Resident COVID-19 Event Form - LTCF

IC 247668 under ICR 202109-0920-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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
0920-1317 Resident COVID-19 Event Form 22SEP2021 VA COVID Reporting RESIDENT Vax.docx	Form and Instruction
0920-1317 Resident COVID-19 Event Form 22SEP2021 VA COVID Reporting RESIDENT Vax.docx	Form and Instruction
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
SVH COVID-19 Resident toi_V8_27April_FINAL.docx Instructions Resident COVID-19 Event Form 22SEP2021	IC Document
SVH COVID-19 Resident toi_V8_27April_FINAL.docx Instructions Resident COVID-19 Event Form 22SEP2021	IC Document
57.155 Table of Instructions for Point of Care Testing (POC) Form 9.5.5_FINAL.docx Instructions for Point of Care Testing Form (CDC 57.155)	IC Document
57.155 Table of Instructions for Point of Care Testing (POC) Form 9.5.5_FINAL.docx Instructions for Point of Care Testing Form (CDC 57.155)	IC Document

IC Title:

VA - Resident COVID-19 Event Form - LTCF

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form and Instruction	0920-1317	Resident COVID-19 Event Form 22SEP2021	VA COVID Reporting RESIDENT Vax.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	Previously Approved
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
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.