Information Collection

Long Term Care Facility Resident Impact and Facility Capacity Pathway

IC 243702 under ICR 202407-0920-003 · OMB 0920-1317.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC 57.144 Long Term Care Facility Resident Impact and Facility Capacity Pathway	Form and Instruction
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

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: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	858,000	858,000
Annual IC Time Burden (Hours)	357,500	357,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.