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

ICR 202404-0920-010

OMB: 0920-1317

Federal Form Document

Forms and Documents

Document Name	Status
Form 57.155 Point of Care Testing Results Form and Instruction	Unchanged
Form 0920-1317 COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities) Form and Instruction	Unchanged
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 - Hospitals (excluding Psychiatric and Rehabilitation Facilities) Form and Instruction	Unchanged
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Form and Instruction	Unchanged
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction	Unchanged
Form CDC Form 57.141 Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction	Unchanged
Form 0920-1317 / CDC Fo Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Form and Instruction	Unchanged
Form 0920-1317 / CDC Fo Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	Modified
Form CDC Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction	Modified
Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form - LTCF Form and Instruction	Unchanged
Form 0920-1317 VA - Resident COVID-19 Event Form - LTCF Form and Instruction	Unchanged
Dialysis Component Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel retrospective Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel Form and Instruction	Unchanged
Form CDC 57.144 Long Term Care Facility Resident Impact and Facility Capacity Pathway Form and Instruction	Unchanged
Form 0920-1317 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction	Unchanged
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx Justification for No Material/Nonsubstantive Change	2024-04-26
Change Memo for CDC NHSN COVID-19 OMB Package 0920-1317.docx Justification for No Material/Nonsubstantive Change	2024-03-14
Resident Impact and Facility Capacity- csv temp..csv Supplementary Document	2023-09-07
TOI-Facility Importing COVID-19 and Respiratory Infections using a .csv file_RIFC.docx Supplementary Document	2023-09-07
Change Memo for NHSN September 2023_0920_1317.docx Justification for No Material/Nonsubstantive Change	2023-09-07
Crosswalk_57.218.docx Supplementary Document	2023-09-07
Crosswalk_57.144.docx Supplementary Document	2023-09-07
Crosswalk-COVID-19 Hospital Data.docx Supplementary Document	2023-09-07
Crosswalk 11.4 updated COVID JUNE_final.docx Supplementary Document	2023-05-18
Change Memo for NHSN May 2023_0920_1317_final.docx Justification for No Material/Nonsubstantive Change	2023-05-18
CDC Response to APIC Dec29 letter sk lw.docx Supplementary Document	2023-03-06
5. NHSN - Report of End of Human Research Review 0.1253.docx Supplementary Document	2022-11-28
6. IRB Protocol Closure.pdf Supplementary Document	2022-11-28
3. Privacy Act Checklist 2022.docx Supplementary Document	2022-11-28
2. Published 60-day FRN.pdf Supplementary Document	2022-11-28
1c. 42 USC 242m.PDF Supplementary Document	2022-11-28
1b. 42 USC 242k.PDF Supplementary Document	2022-11-28
1a. 42 USC 242b.PDF Supplementary Document	2022-11-28
SSB 0920-1317 NHSN COVID-19 Module.docx Supporting Statement B	2022-11-29
SSA 0920-1317 NHSN COVID-19 Module_final.docx Supporting Statement A	2022-11-30

IC Document Collections

IC ID	Document Title	Status
266012	Point of Care Testing Results Form and Instruction	Unchanged
262062	COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities) Form and Instruction	Unchanged
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	Unchanged
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
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
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	Modified
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
243719	Dialysis Component Form and Instruction	Unchanged
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
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
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
243702	Long Term Care Facility Resident Impact and Facility Capacity Pathway Form and Instruction	Unchanged
243698	NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction	Unchanged