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

[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⚠️ Notice: This information collection may be referencing outdated material.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 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

Information Collection (IC) Details

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:

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 %

	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

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.