Information Collection

COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities)

IC 262062 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⚠️ Notice: This information collection may be referencing outdated material.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 0920-1317 COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities)	Form and Instruction
Form 0920-1317 COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities)	Form and Instruction
0920-1317 COVID-19 Hospital Data Form Form-COVID-19 Hospital Data Form-Clean Version.docx	Form and Instruction
0920-1317 COVID-19 Hospital Data Form Form-COVID-19 Hospital Data Form-Clean Version.docx	Form and Instruction
TOI-for Completion of the COVID-19 Hospital Data Reporting Form.docx TOI COVID-19 Hospital Module Form	IC Document
TOI-for Completion of the COVID-19 Hospital Data Reporting Form.docx TOI COVID-19 Hospital Module Form	IC Document

IC Title:

COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	0920-1317	COVID-19 Hospital Data Form	Form-COVID-19 Hospital Data Form-Clean Version.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: 870

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
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-870	870
Annual IC Time Burden (Hours)	-1,305	1,305
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
TOI COVID-19 Hospital Module Form	TOI-for Completion of the COVID-19 Hospital Data Reporting Form.docx	09/07/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.