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Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202407-0920-003 · OMB 0920-1317 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 57.102 57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction New Available
Form 57.102 57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction New Repair queued
Form 57.102 57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction New Available
Form 57.102 57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction New Repair queued
Form 57.102 57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction New Available
Form 57.102 57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction New Missing upstream
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction New Available
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction New Repair queued
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction New Available
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction New Repair queued
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction New Repair queued
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction New Missing upstream
Form 57.155 Point of Care Testing Results Form and Instruction Unchanged Repair queued
Form 57.155 Point of Care Testing Results Form and Instruction Unchanged Missing upstream
Form 0920-1317 COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities) Form and Instruction Removed Available
Form 0920-1317 COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities) Form and Instruction Removed Repair queued
NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs) 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
NHSN COVID-19 Hospital Module - Hospitals (excluding Psychiatric and Rehabilitation Facilities) Form and Instruction Removed Available
NHSN COVID-19 Hospital Module - Hospitals (excluding Psychiatric and Rehabilitation Facilities) Form and Instruction Removed Repair queued
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities 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 - completed by Dialysis Facilities Form and Instruction Unchanged Available
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction Unchanged Missing upstream
Form CDC Form 57.141 Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction Unchanged Available
Form CDC Form 57.141 Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction Unchanged Repair queued
Form 0920-1317 / CDC Fo Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Form and Instruction Unchanged Repair queued
Form 0920-1317 / CDC Fo Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Form and Instruction Unchanged Repair queued
Form 0920-1317 / CDC Fo Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Unchanged Repair queued
Form 0920-1317 / CDC Fo Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Unchanged Missing upstream
Form CDC Form 57.219 Weekly 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 Missing upstream
Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form - LTCF 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 - Resident COVID-19 Event Form - LTCF Form and Instruction Unchanged Available
Form 0920-1317 VA - Resident COVID-19 Event Form - LTCF Form and Instruction Unchanged Repair queued
Dialysis Component Form and Instruction Unchanged Repair queued
Dialysis Component Form and Instruction Unchanged Repair queued
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 - State and Local Health Dept Occupations retrospective Form and Instruction Unchanged Repair queued
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Form and Instruction Unchanged Available
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 - LTCF Personnel retrospective 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 - State and Local Health Dept Occupations Form and Instruction Unchanged Available
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations Form and Instruction Unchanged Missing upstream
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations 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 - LTCF Personnel 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 Long Term Care Facility Resident Impact and Facility Capacity Pathway Form and Instruction Unchanged Available
Form CDC 57.144 Long Term Care Facility Resident Impact and Facility Capacity Pathway Form and Instruction Unchanged Repair queued
Form 0920-1317 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction Unchanged Repair queued
Form 0920-1317 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction Unchanged Missing upstream
Change Memo 0920-1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-08-06 Available
Change Memo 0920-1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-08-06 Repair queued
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-04-26 Available
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-04-26 Repair queued
Change Memo for CDC NHSN COVID-19 OMB Package 0920-1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-03-14 Available
Change Memo for CDC NHSN COVID-19 OMB Package 0920-1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-03-14 Repair queued
Resident Impact and Facility Capacity- csv temp..csv Supplementary Document Uploaded 2023-09-07 Available
Resident Impact and Facility Capacity- csv temp..csv Supplementary Document Uploaded 2023-09-07 Missing upstream
TOI-Facility Importing COVID-19 and Respiratory Infections using a .csv file_RIFC.docx Supplementary Document Uploaded 2023-09-07 Available
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 Repair queued
Change Memo for NHSN September 2023_0920_1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2023-09-07 Repair queued
Crosswalk_57.218.docx Supplementary Document 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 Available
Crosswalk_57.144.docx Supplementary Document Uploaded 2023-09-07 Repair queued
Crosswalk-COVID-19 Hospital Data.docx Supplementary Document Uploaded 2023-09-07 Available
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
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 Available
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 Available
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 Available
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
6. IRB Protocol Closure.pdf Supplementary Document Uploaded 2022-11-28 Missing upstream
3. Privacy Act Checklist 2022.docx Supplementary Document Uploaded 2022-11-28 Available
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 Available
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 Available
1c. 42 USC 242m.PDF Supplementary Document Uploaded 2022-11-28 Repair queued
1b. 42 USC 242k.PDF Supplementary Document Uploaded 2022-11-28 Available
1b. 42 USC 242k.PDF Supplementary Document Uploaded 2022-11-28 Repair queued
1a. 42 USC 242b.PDF Supplementary Document Uploaded 2022-11-28 Available
1a. 42 USC 242b.PDF Supplementary Document Uploaded 2022-11-28 Missing upstream
SSB 0920-1317 NHSN COVID-19 Module.docx Supporting Statement B Uploaded 2022-11-29 Available
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 Available
SSA 0920-1317 NHSN COVID-19 Module_final.docx Supporting Statement A Uploaded 2022-11-30 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
269868 57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction New
269868 57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction New
269867 57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction New
269867 57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction New
269866 57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction New
269866 57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction New
269865 57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction New
269865 57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction New
269864 57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction New
269864 57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction New
269863 57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction New
269863 57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction New
266012 Point of Care Testing Results Form and Instruction Unchanged
266012 Point of Care Testing Results Form and Instruction Unchanged
262062 COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities) Form and Instruction Removed
262062 COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities) Form and Instruction Removed
257194 NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs) 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 Removed
257193 NHSN COVID-19 Hospital Module - Hospitals (excluding Psychiatric and Rehabilitation Facilities) Form and Instruction Removed
249439 Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric 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
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
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
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 Unchanged
249435 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction Unchanged
249434 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction Unchanged
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
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
247668 VA - Resident COVID-19 Event Form - LTCF Form and Instruction Unchanged
243719 Dialysis Component 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
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
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
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
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
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
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
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
243698 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction Unchanged
ICR Details
StatusHistorical Active
Agency/SubagencyHHS/CDC
OMB Control No0920-1317
Type of Information CollectionNo material or nonsubstantive change to a currently approved collection
Previous ICR Reference No202404-0920-010
Agency Tracking No0920-1317-24HR
Date Submitted to OIRA2024-08-06
Requested Expiration Date1969-12-31