OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202211-0920-014 · OMB 0920-1317 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs) Form and Instruction New Repair queued
NHSN COVID-19 Hospital Module (Hospitals) Form and Instruction New Repair queued
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Form and Instruction Modified Repair queued
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction Modified Missing upstream
Form CDC Form 57.141 Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction Modified Repair queued
Form 0920-1317 / CDC Fo Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Form and Instruction Modified Repair queued
Form 0920-1317 / CDC Fo Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Modified Repair queued
Form CDC Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction Modified Repair queued
Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form - LTCF Form and Instruction Modified Repair queued
Form 0920-1317 VA - Resident COVID-19 Event Form - LTCF Form and Instruction Modified Repair queued
Form 0920-1317 CDC 57.X Resident Therapeutics - State and Local Health Dept. Occupations Form and Instruction Modified Repair queued
Form 0920-1317 CDC 57.X Resident Therapeutics - Business and Financial Operations Occupations Form and Instruction Modified Repair queued
Form 0920-1317 CDC 57.X Resident Therapeutics - LTCF Personnel Form and Instruction Modified Repair queued
Dialysis Component Form and Instruction Modified Repair queued
Form CDC 57.147 Ventilator Capacity & Supplies - State and Local Health Dept Occupations Form and Instruction Removed Missing upstream
Form CDC 57.147 Ventilator Capacity & Supplies - Business and Financial Operations Occupations Form and Instruction Removed Repair queued
Form CDC 57.147 Ventilator Capacity & Supplies - LCTF Personnel Form and Instruction Removed Repair queued
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Form and Instruction Modified Repair queued
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Form and Instruction Modified Repair queued
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel retrospective Form and Instruction Modified Repair queued
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations Form and Instruction Modified Repair queued
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations Form and Instruction Modified Repair queued
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel Form and Instruction Modified Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective Form and Instruction Modified Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective Form and Instruction Modified Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity - LTCF Personnel retrospective Form and Instruction Modified Missing upstream
Form CDC 57.144 Resident Impact and Facility Capacity - State and Local Health Dept Occupations Form and Instruction Removed Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity - Business and Financial Operations Occupations Form and Instruction Removed Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity - LTCF Personnel, Business and Financial operations and State and Local Health Dept. Occupations Form and Instruction Modified Repair queued
Form 0920-1317 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction Modified Repair queued
5. NHSN - Report of End of Human Research Review 0.1253.docx Supplementary Document Uploaded 2022-11-28 Repair queued
6. IRB Protocol Closure.pdf Supplementary Document Uploaded 2022-11-28 Missing upstream
3. Privacy Act Checklist 2022.docx Supplementary Document Uploaded 2022-11-28 Repair queued
2. Published 60-day FRN.pdf Supplementary Document Uploaded 2022-11-28 Repair queued
1c. 42 USC 242m.PDF Supplementary Document Uploaded 2022-11-28 Repair queued
1b. 42 USC 242k.PDF Supplementary Document Uploaded 2022-11-28 Repair queued
1a. 42 USC 242b.PDF Supplementary Document Uploaded 2022-11-28 Repair queued
SSB 0920-1317 NHSN COVID-19 Module.docx Supporting Statement B Uploaded 2022-11-29 Repair queued
SSA 0920-1317 NHSN COVID-19 Module_final.docx Supporting Statement A Uploaded 2022-11-30 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
257194 NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs) Form and Instruction New
257193 NHSN COVID-19 Hospital Module (Hospitals) Form and Instruction New
249439 Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Form and Instruction Modified
249438 Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction Modified
249437 Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction Modified
249436 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Form and Instruction Modified
249435 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Modified
249434 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction Modified
247669 VA - Staff and Personnel COVID-19 Event Form - LTCF Form and Instruction Modified
247668 VA - Resident COVID-19 Event Form - LTCF Form and Instruction Modified
245466 Resident Therapeutics - State and Local Health Dept. Occupations Form and Instruction Modified
245464 Resident Therapeutics - Business and Financial Operations Occupations Form and Instruction Modified
245463 Resident Therapeutics - LTCF Personnel Form and Instruction Modified
243719 Dialysis Component Form and Instruction Modified
243718 Ventilator Capacity & Supplies - State and Local Health Dept Occupations Form and Instruction Removed
243717 Ventilator Capacity & Supplies - Business and Financial Operations Occupations Form and Instruction Removed
243716 Ventilator Capacity & Supplies - LCTF Personnel Form and Instruction Removed
243711 Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Form and Instruction Modified
243710 Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Form and Instruction Modified
243709 Staff and Personnel Impact - LTCF Personnel retrospective Form and Instruction Modified
243708 Staff and Personnel Impact - State and Local Health Dept Occupations Form and Instruction Modified
243707 Staff and Personnel Impact - Business and Financial Operations Occupations Form and Instruction Modified
243706 Staff and Personnel Impact - LTCF Personnel Form and Instruction Modified
243704 Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective Form and Instruction Modified
243703 Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective Form and Instruction Modified
243702 Resident Impact and Facility Capacity - LTCF Personnel retrospective Form and Instruction Modified
243701 Resident Impact and Facility Capacity - State and Local Health Dept Occupations Form and Instruction Removed
243700 Resident Impact and Facility Capacity - Business and Financial Operations Occupations Form and Instruction Removed
243699 Resident Impact and Facility Capacity - LTCF Personnel, Business and Financial operations and State and Local Health Dept. Occupations Form and Instruction Modified
243698 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction Modified
ICR Details
StatusReceived in OIRA
Agency/SubagencyHHS/CDC
OMB Control No0920-1317
Type of Information CollectionRevision of a currently approved collection
Previous ICR Reference No202207-0920-002
Agency Tracking No0920-1317
Date Submitted to OIRA1969-12-31
Requested Expiration Date1969-12-31