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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1317 COVID-19 Hospital Data Form	Form and Instruction	New	Available
Form 0920-1317 COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities)	Form and Instruction	New	Repair queued
NHSN COVID-19 Hospital Module Infusion Centers and Outpatient Clinics	Form and Instruction	Unchanged	Available
NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs)	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 COVID-19 Hospital Data Form	Form and Instruction	Modified	Available
NHSN COVID-19 Hospital Module	Form and Instruction	Modified	Available
NHSN COVID-19 Hospital Module - Hospitals (excluding Psychiatric and Rehabilitation Facilities)	Form and Instruction	Modified	Repair queued
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan	Form and Instruction	Unchanged	Available
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities	Form and Instruction	Unchanged	Repair queued
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan	Form and Instruction	Unchanged	Available
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	Form and Instruction	Unchanged	Repair queued
Form CDC Form 57.141 Monthly Reporting Plan for LTCF	Form and Instruction	Unchanged	Available
Form CDC Form 57.141 Monthly Reporting Plan form for Long-term Care Facilities	Form and Instruction	Unchanged	Available
Form 0920-1317 / CDC Fo Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients	Form and Instruction	Unchanged	Available
Form 0920-1317 / CDC Fo Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	Form and Instruction	Unchanged	Repair queued
Form 57.218 Weekly Vaccination Cumulative Summary for Residents of Long-Term Care Facilities (57.218)	Form and Instruction	Modified	Available
Form 0920-1317 / CDC Fo Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities	Form and Instruction	Modified	Available
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 Healthcare Personnel COVID-19 Vaccination Cumulative Summary	Form and Instruction	Unchanged	Available
Form CDC Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form	Form and Instruction	Unchanged	Available
Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form - LTCF	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 VA COVID-19 Resident Event Form	Form and Instruction	Unchanged	Available
Form 0920-1317 VA - Resident COVID-19 Event Form - LTCF	Form and Instruction	Unchanged	Repair queued
COVID–19 Module - Dialysis Outpatient Facility	Form and Instruction	Unchanged	Available
Dialysis Component	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations retrospective	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations retrospective	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel retrospective	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Repair queued
Form CDC 57.145 Staff and Personnel Impact	Form and Instruction	Unchanged	Available
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel	Form and Instruction	Unchanged	Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity	Form and Instruction	Removed	Available
Form CDC 57.144 Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective	Form and Instruction	Removed	Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity	Form and Instruction	Removed	Available
Form CDC 57.144 Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective	Form and Instruction	Removed	Repair queued
Form 57.144 COVID-19 and Respiratory Infections Module Long Term Care Facility Resident Impact and Facility Capacity Pathway Form (57.144) 07SEP2023	Form and Instruction	Modified	Available
Form CDC 57.144 Resident Impact and Facility Capacity	Form and Instruction	Modified	Available
Form CDC 57.144 Long Term Care Facility Resident Impact and Facility Capacity Pathway	Form and Instruction	Modified	Repair queued
Form CDC 57.144 Resident Impact and Facility Capacity	Form and Instruction	Removed	Available
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	Removed	Available
Form 0920-1317 NHSN Registration Form	Form and Instruction	Unchanged	Available
Form 0920-1317 NHSN and Secure Access Management Services (SAMS) enrollment	Form and Instruction	Unchanged	Repair queued
Resident Impact and Facility Capacity- csv temp..csv	Supplementary Document	Uploaded 2023-09-07	Repair queued
TOI-Facility Importing COVID-19 and Respiratory Infections using a .csv file_RIFC.docx	Supplementary Document	Uploaded 2023-09-07	Repair queued
Change Memo for NHSN September 2023_0920_1317.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-09-07	Available
Crosswalk_57.218.docx	Supplementary Document	Uploaded 2023-09-07	Repair queued
Crosswalk_57.144.docx	Supplementary Document	Uploaded 2023-09-07	Repair queued
Crosswalk-COVID-19 Hospital Data.docx	Supplementary Document	Uploaded 2023-09-07	Repair queued
Crosswalk 11.4 updated COVID JUNE_final.docx	Supplementary Document	Uploaded 2023-05-18	Repair queued
Change Memo for NHSN May 2023_0920_1317_final.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-05-18	Repair queued
CDC Response to APIC Dec29 letter sk lw.docx	Supplementary Document	Uploaded 2023-03-06	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	Repair queued
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

Information collection document groups

IC ID	Collection	Type	Status	Form
262062	COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities)	Form and Instruction	New	COVID-19 Hospital Data Form
262062	COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities)	Form and Instruction	New
257194	NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs)	Form and Instruction	Unchanged	NHSN COVID-19 Hospital Module Infusion Centers and Outpatient Clinics
257194	NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs)	Form and Instruction	Unchanged
257193	NHSN COVID-19 Hospital Module - Hospitals (excluding Psychiatric and Rehabilitation Facilities)	Form and Instruction	Modified	COVID-19 Hospital Data Form
257193	NHSN COVID-19 Hospital Module - Hospitals (excluding Psychiatric and Rehabilitation Facilities)	Form and Instruction	Modified	NHSN COVID-19 Hospital Module
257193	NHSN COVID-19 Hospital Module - Hospitals (excluding Psychiatric and Rehabilitation Facilities)	Form and Instruction	Modified
249439	Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities	Form and Instruction	Unchanged	Healthcare Personnel Safety Monthly Reporting Plan
249439	Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities	Form and Instruction	Unchanged
249438	Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	Form and Instruction	Unchanged	Healthcare Personnel Safety Monthly Reporting Plan
249438	Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	Form and Instruction	Unchanged
249437	Monthly Reporting Plan form for Long-term Care Facilities	Form and Instruction	Unchanged	Monthly Reporting Plan for LTCF
249437	Monthly Reporting Plan form for Long-term Care Facilities	Form and Instruction	Unchanged
249436	Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	Form and Instruction	Unchanged	Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients
249436	Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	Form and Instruction	Unchanged
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Modified	Weekly Vaccination Cumulative Summary for Residents of Long-Term Care Facilities (57.218)
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities	Form and Instruction	Modified	Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities
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	Unchanged	Healthcare Personnel COVID-19 Vaccination Cumulative Summary
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary	Form and Instruction	Unchanged
247669	VA - Staff and Personnel COVID-19 Event Form - LTCF	Form and Instruction	Unchanged	VA - Staff and Personnel COVID-19 Event Form
247669	VA - Staff and Personnel COVID-19 Event Form - LTCF	Form and Instruction	Unchanged
247668	VA - Resident COVID-19 Event Form - LTCF	Form and Instruction	Unchanged	VA COVID-19 Resident Event Form
247668	VA - Resident COVID-19 Event Form - LTCF	Form and Instruction	Unchanged
243719	Dialysis Component	Form and Instruction	Unchanged	COVID–19 Module - Dialysis Outpatient Facility
243719	Dialysis Component	Form and Instruction	Unchanged
243711	Staff and Personnel Impact - State and Local Health Dept Occupations retrospective	Form and Instruction	Unchanged	Staff and Personnel Impact
243711	Staff and Personnel Impact - State and Local Health Dept Occupations retrospective	Form and Instruction	Unchanged
243710	Staff and Personnel Impact - Business and Financial Operations Occupations retrospective	Form and Instruction	Unchanged	Staff and Personnel Impact
243710	Staff and Personnel Impact - Business and Financial Operations Occupations retrospective	Form and Instruction	Unchanged
243709	Staff and Personnel Impact - LTCF Personnel retrospective	Form and Instruction	Unchanged	Staff and Personnel Impact
243709	Staff and Personnel Impact - LTCF Personnel retrospective	Form and Instruction	Unchanged
243708	Staff and Personnel Impact - State and Local Health Dept Occupations	Form and Instruction	Unchanged	Staff and Personnel Impact
243708	Staff and Personnel Impact - State and Local Health Dept Occupations	Form and Instruction	Unchanged
243707	Staff and Personnel Impact - Business and Financial Operations Occupations	Form and Instruction	Unchanged	Staff and Personnel Impact
243707	Staff and Personnel Impact - Business and Financial Operations Occupations	Form and Instruction	Unchanged
243706	Staff and Personnel Impact - LTCF Personnel	Form and Instruction	Unchanged	Staff and Personnel Impact
243706	Staff and Personnel Impact - LTCF Personnel	Form and Instruction	Unchanged
243704	Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective	Form and Instruction	Removed	Resident Impact and Facility Capacity
243704	Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective	Form and Instruction	Removed
243703	Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective	Form and Instruction	Removed	Resident Impact and Facility Capacity
243703	Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective	Form and Instruction	Removed
243702	Long Term Care Facility Resident Impact and Facility Capacity Pathway	Form and Instruction	Modified	COVID-19 and Respiratory Infections Module Long Term Care Facility Resident Impact and Facility Capacity Pathway Form (57.144) 07SEP2023
243702	Long Term Care Facility Resident Impact and Facility Capacity Pathway	Form and Instruction	Modified	Resident Impact and Facility Capacity
243702	Long Term Care Facility Resident Impact and Facility Capacity Pathway	Form and Instruction	Modified
243699	Resident Impact and Facility Capacity - LTCF Personnel, Business and Financial operations and State and Local Health Dept. Occupations	Form and Instruction	Removed	Resident Impact and Facility Capacity
243699	Resident Impact and Facility Capacity - LTCF Personnel, Business and Financial operations and State and Local Health Dept. Occupations	Form and Instruction	Removed
243698	NHSN and Secure Access Management Services (SAMS) enrollment	Form and Instruction	Unchanged	NHSN Registration Form
243698	NHSN and Secure Access Management Services (SAMS) enrollment	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-1317	ICR Reference No: 202309-0920-001
Status: Historical Active	Previous ICR Reference No: 202305-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1317-23IC
Title: [NCEZID] National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/16/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/07/2023
Terms of Clearance: OMB considers this to be a non-substantive change to an approved collection because it does not introduce new concepts that have not previously received public comment and minimally impacts burden (as several of the proposed changed responses are optional). This determination is specific to this approval only; future requests will be independently evaluated based on their individual facts and circumstances. Previous Terms of Clearance continue: CDC will work with its OIRA desk officer should changes be necessary. CDC will detail in all publications and use of the data any limitations based upon changes in respondent characteristics.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2026	03/31/2026	03/31/2026
Responses	6,519,463	0	6,867,726
Time Burden (Hours)	5,614,755	0	6,523,629
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of this information collection is to 1) capture the daily, aggregate impact of COVID-19 on healthcare facilities, and 2) monitor medical capacity to respond at local, state, and national levels. This information will be used to inform the overall real-time COVID-19 response efforts and possible resource allocation, and enable state and local health departments to gain immediate access to the COVID-19 data for healthcare facilities within their jurisdiction. This Change Request is submitted to modify the following forms: 1. Hospital COVID-19 Data Collection Form 2. Weekly Vaccination Cumulative Summary for Residents of Long-Term Care Facilities (57.218) 3. COVID-19 and Respiratory Infections Module Long Term Care Facility Resident Impact and Facility Capacity Pathway Form (57.144) Modifications include addition of optional data elements regarding RSV and influenza.

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Authorizing Statute(s): US Code: 42 USC 242b, k, m Name of Law: The Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 55815	09/12/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 73309	11/29/2022
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 20

table that charts list of burden

IC Title	Form No.	Form Name
COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities)	0920-1317	COVID-19 Hospital Data Form
Dialysis Component	n/a	COVID–19 Module - Dialysis Outpatient Facility
Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	CDC Form 57.203	Healthcare Personnel Safety Monthly Reporting Plan
Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities	CDC Form 57.203	Healthcare Personnel Safety Monthly Reporting Plan
Long Term Care Facility Resident Impact and Facility Capacity Pathway	57.144, CDC 57.144	Resident Impact and Facility Capacity ,   COVID-19 and Respiratory Infections Module Long Term Care Facility Resident Impact and Facility Capacity Pathway Form (57.144) 07SEP2023
Monthly Reporting Plan form for Long-term Care Facilities	CDC Form 57.141	Monthly Reporting Plan for LTCF
NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs)	n/a	NHSN COVID-19 Hospital Module Infusion Centers and Outpatient Clinics
NHSN COVID-19 Hospital Module - Hospitals (excluding Psychiatric and Rehabilitation Facilities)	n/a, 0920-1317	NHSN COVID-19 Hospital Module ,   COVID-19 Hospital Data Form
NHSN and Secure Access Management Services (SAMS) enrollment	0920-1317	NHSN Registration Form
Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective	CDC 57.144	Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - LTCF Personnel, Business and Financial operations and State and Local Health Dept. Occupations	CDC 57.144	Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective	CDC 57.144	Resident Impact and Facility Capacity
Staff and Personnel Impact - Business and Financial Operations Occupations	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - Business and Financial Operations Occupations retrospective	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel retrospective	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations retrospective	CDC 57.145	Staff and Personnel Impact
VA - Resident COVID-19 Event Form - LTCF	0920-1317	VA COVID-19 Resident Event Form
VA - Staff and Personnel COVID-19 Event Form - LTCF	0920-1317	VA - Staff and Personnel COVID-19 Event Form
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary	CDC Form 57.219	Healthcare Personnel COVID-19 Vaccination Cumulative Summary
Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	0920-1317 / CDC Form 57.509	Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities	57.218, 0920-1317 / CDC Form 57.218	Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities ,   Weekly Vaccination Cumulative Summary for Residents of Long-Term Care Facilities (57.218)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	6,519,463	6,867,726	0	-348,263	0	0
Annual Time Burden (Hours)	5,614,755	6,523,629	0	-908,874	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Forms

Short Statement: Change Request for 0920-1317 makes modifications to three previously approved forms: 1. Hospital COVID-19 Data Collection Form 2. Weekly Vaccination Cumulative Summary for Residents of Long-Term Care Facilities (57.218) 3. COVID-19 and Respiratory Infections Module Long Term Care Facility Resident Impact and Facility Capacity Pathway Form (57.144)

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/07/2023

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