Information Collection

Resident Impact and Facility Capacity - LTCF Personnel

IC 243699 under ICR 202205-0920-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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 CDC 57.144 Resident Impact and Facility Capacity - LTCF Personnel	Form and Instruction
CDC 57.144 Resident Impact and Facility Capacity CDC 57.144_COVID-19 form_Resident Impact and Facility Capacity_v2 updated 6.2020 Final.docx	Form and Instruction
CDC 57.144 Resident Impact and Facility Capacity CDC 57.144_COVID-19 form_Resident Impact and Facility Capacity_v2 updated 6.2020 Final.docx	Form and Instruction
0920-1317 CDC 57.1 Resident Impact and Facility Capacity 57.144-LTCF_RIFC_V6.docx	Form and Instruction
0920-1317 CDC 57.1 Resident Impact and Facility Capacity 57.144-LTCF_RIFC_V6.docx	Form and Instruction
0920-1317 Form 57. Resident Impact and Facility Capacity Form 21SEP2021 57.144-RIFC form_v10 OMB_FINAL.docx	Form and Instruction
0920-1317 Form 57. Resident Impact and Facility Capacity Form 21SEP2021 57.144-RIFC form_v10 OMB_FINAL.docx	Form and Instruction
0920-1317 / CDC 57 Resident Impact and Facility Capacity Form 23MAY2022 57.144 RICF form 10.1.3 OMB.docx	Form and Instruction
0920-1317 / CDC 57 Resident Impact and Facility Capacity Form 23MAY2022 57.144 RICF form 10.1.3 OMB.docx	Form and Instruction
57.144-RIFC toi_V13_10.1.3 OMB.docx RIFC - Instructions	IC Document
57.144-RIFC toi_V13_10.1.3 OMB.docx RIFC - Instructions	IC Document

IC Title:

Resident Impact and Facility Capacity - LTCF Personnel

Agency IC Tracking Number:

0920-20LW

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 and Instruction	CDC 57.144	Resident Impact and Facility Capacity	CDC 57.144_COVID-19 form_Resident Impact and Facility Capacity_v2 updated 6.2020 Final.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1317 CDC 57.144	Resident Impact and Facility Capacity	57.144-LTCF_RIFC_V6.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1317 Form 57.144	Resident Impact and Facility Capacity Form 21SEP2021	57.144-RIFC form_v10 OMB_FINAL.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1317 / CDC 57.144	Resident Impact and Facility Capacity Form 23MAY2022	57.144 RICF form 10.1.3 OMB.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: 16,512

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	858,624	0	858,624
Annual IC Time Burden (Hours)	643,968	-214,656	858,624
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
RIFC - Instructions	57.144-RIFC toi_V13_10.1.3 OMB.docx	05/23/2022

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