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VA - Resident COVID-19 Event Form - LTCF
[NCEZID] National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities
OMB: 0920-1317
IC ID: 247668
OMB.report
HHS/CDC
OMB 0920-1317
ICR 202305-0920-005
IC 247668
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1317 can be found here:
2024-08-06 - No material or nonsubstantive change to a currently approved collection
2024-04-26 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Form 0920-1317
VA - Resident COVID-19 Event Form - LTCF
Form and Instruction
0920-1317 VA COVID-19 Resident Event Form
Clean 10.1.4 COVID 19 event reporting_resident form revised_7.22.docx
Form and Instruction
0920-1317 VA COVID-19 Resident Event Form
Clean 10.1.4 COVID 19 event reporting_resident form revised_7.22.docx
Form and Instruction
Clean 10.1.4 SVH COVID-19 Resident toi_V9_7.22.docx
INSTRUCTIONS - Resident COVID-19 Event Form JUL2022
IC Document
Clean 10.1.4 SVH COVID-19 Resident toi_V9_7.22.docx
INSTRUCTIONS - Resident COVID-19 Event Form JUL2022
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
VA - Resident COVID-19 Event Form - LTCF
Agency IC Tracking Number:
0920-1317
Is this a Common Form?
No
IC Status:
Unchanged
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
VA COVID-19 Resident Event Form
Clean 10.1.4 COVID 19 event reporting_resident form revised_7.22.docx
NA
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
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 %
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)
3,948
0
0
0
0
3,948
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
INSTRUCTIONS - Resident COVID-19 Event Form JUL2022
Clean 10.1.4 SVH COVID-19 Resident toi_V9_7.22.docx
11/29/2022
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.