VA - Staff and Personnel COVID-19 Event Form - LTCF

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

OMB: 0920-1317

IC ID: 247669

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VA - Staff and Personnel 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 - Staff and Personnel COVID-19 Event Form VA Covid-19 Reporting_Staff v7_13May_CLEAN.docx NA Yes Yes Fillable Fileable
Form and Instruction 0920-1317 Staff and Personnel COVID-19 Event Form 22SEP2021 VA COVID Reporting STAFF 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) 2,820 0 0 0 0 2,820
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Instructions - VA - Staff and Personnel COVID-19 Event Form VA COVID-19 toi_staff v5_27April_CLEAN.docx 05/28/2021
Instructions VA Staff and Personnel COVID-19 Event Form 22SEP2021 SVH COVID-19 toi_staff v6_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
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