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Long Term Care Facility Resident Impact and Facility Capacity Pathway
[NCEZID] National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities
OMB: 0920-1317
IC ID: 243702
OMB.report
HHS/CDC
OMB 0920-1317
ICR 202309-0920-001
IC 243702
( )
⚠️ Notice: This information collection may be referencing outdated material.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 CDC 57.144
Long Term Care Facility Resident Impact and Facility Capacity Pathway
Form and Instruction
CDC 57.144 Resident Impact and Facility Capacity
57.144 RIFC form v13 final 5.3.23_CLEAN.docx
Form and Instruction
CDC 57.144 Resident Impact and Facility Capacity
57.144 RIFC form v13 final 5.3.23_CLEAN.docx
Form and Instruction
57.144 COVID-19 and Respiratory Infections Module Long Term Car
Form-COVID-19_Respiratory Infections Module LTCF_RIFC 57.144-Clean.docx
Form and Instruction
57.144 COVID-19 and Respiratory Infections Module Long Term Car
Form-COVID-19_Respiratory Infections Module LTCF_RIFC 57.144-Clean.docx
Form and Instruction
TOI 57.144.docx
TOI - Form 57.144
IC Document
TOI 57.144.docx
TOI - Form 57.144
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Long Term Care Facility Resident Impact and Facility Capacity Pathway
Agency IC Tracking Number:
0920-1317
Is this a Common Form?
No
IC Status:
Modified
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
CDC 57.144
Resident Impact and Facility Capacity
57.144 RIFC form v13 final 5.3.23_CLEAN.docx
Yes
Yes
Fillable Fileable
Form and Instruction
57.144
COVID-19 and Respiratory Infections Module Long Term Care Facility Resident Impact and Facility Capacity Pathway Form (57.144) 07SEP2023
Form-COVID-19_Respiratory Infections Module LTCF_RIFC 57.144-Clean.docx
N/A
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:
16,500
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
858,000
0
852,189
0
0
5,811
Annual IC Time Burden (Hours)
357,500
0
356,047
0
0
1,453
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
TOI - Form 57.144
TOI 57.144.docx
09/07/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.