Information Collection

VA - Resident COVID-19 Event Form - LTCF

IC 247668 under ICR 202305-0920-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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	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

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	6,768	6,768
Annual IC Time Burden (Hours)	3,948	3,948
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.