Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 0920-1317 / CDC Fo Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction
0920-1317 / CDC Fo Weekly COVID-19 Vaccination Cumulative Summary for Resid COVIDVax.LTC.Resident.FORM_September2021_FINAL.docx Form and Instruction
0920-1317 / CDC Fo Weekly COVID-19 Vaccination Cumulative Summary for Resid COVIDVax.LTC.Resident.FORM_September2021_FINAL.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1317 / CDC Form 57.218	Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities	COVIDVax.LTC.Resident.FORM_September2021_FINAL.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: 16,864	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	876,928	876,928
Annual IC Time Burden (Hours)	1,096,160	1,096,160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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