Long Term Care Facility Resident Impact and Facility Capacity Pathway

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1317 can be found here:

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

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

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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	858,000	852,189	5,811
Annual IC Time Burden (Hours)	357,500	356,047	1,453
Annual IC Cost Burden (Dollars)	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.