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

Forms and Documents

Document	Type	Status	Availability
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv)	Form and Instruction	New	Available
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv)	Form and Instruction	New	Repair queued
Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv)	Form and Instruction	New	Repair queued
Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv)	Form and Instruction	New	Repair queued
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv)	Form and Instruction	New	Repair queued
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv)	Form and Instruction	New	Repair queued
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual)	Form and Instruction	New	Available
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual)	Form and Instruction	New	Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv)	Form and Instruction	New	Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv)	Form and Instruction	New	Repair queued
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)	Form and Instruction	New	Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)	Form and Instruction	New	Repair queued
Form 57.102 57.102 - Hospital Respiratory Data Fomr (Daily - API)	Form and Instruction	Unchanged	Available
Form 57.102 57.102 - Hospital Respiratory Data Fomr (Daily - API)	Form and Instruction	Unchanged	Missing upstream
Form 57.102 57.102 Hospital Respiratory Data Form (Daily - .csv import)	Form and Instruction	Unchanged	Repair queued
Form 57.102 57.102 Hospital Respiratory Data Form (Daily - .csv import)	Form and Instruction	Unchanged	Missing upstream
Form 57.102 57.102 - Hospital Respiratory Data Form (Daily - user entry)	Form and Instruction	Unchanged	Available
Form 57.102 57.102 - Hospital Respiratory Data Form (Daily - user entry)	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - API)	Form and Instruction	Unchanged	Available
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - API)	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - .csv import)	Form and Instruction	Unchanged	Available
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - .csv import)	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - User Entry)	Form and Instruction	Unchanged	Available
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - User Entry)	Form and Instruction	Unchanged	Repair queued
Form 57.155 Point of Care Testing Results	Form and Instruction	Unchanged	Available
Form 57.155 Point of Care Testing Results	Form and Instruction	Unchanged	Repair queued
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 (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs)	Form and Instruction	Unchanged	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	Repair queued
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	Form and Instruction	Unchanged	Repair queued
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	Available
Form 0920-1317 / CDC Fo Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	Form and Instruction	Unchanged	Available
Form 0920-1317 / CDC Fo Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	Form and Instruction	Unchanged	Repair queued
Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual)	Form and Instruction	Modified	Available
Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual)	Form and Instruction	Modified	Repair queued
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual)	Form and Instruction	Modified	Available
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual)	Form and Instruction	Modified	Repair queued
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	Missing upstream
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	Missing upstream
Dialysis Component	Form and Instruction	Unchanged	Available
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	Available
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	Repair queued
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations retrospective	Form and Instruction	Unchanged	Missing upstream
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	Missing upstream
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	Repair queued
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	Missing upstream
Form CDC 57.144 Long Term Care Facility Resident Impact and Facility Capacity Pathway	Form and Instruction	Unchanged	Repair queued
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	Available
Form 0920-1317 NHSN and Secure Access Management Services (SAMS) enrollment	Form and Instruction	Unchanged	Missing upstream
Change Memo 0920-1317 August 2024_FINAL_v2.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-08-22	Available
Change Memo 0920-1317 August 2024_FINAL_v2.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-08-22	Repair queued
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	Repair queued
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-04-26	Missing upstream
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	Repair queued
Resident Impact and Facility Capacity- csv temp..csv	Supplementary Document	Uploaded 2023-09-07	Repair queued
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	Available
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	Available
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	Available
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	Repair queued
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	Missing upstream
1a. 42 USC 242b.PDF	Supplementary Document	Uploaded 2022-11-28	Repair queued
1a. 42 USC 242b.PDF	Supplementary Document	Uploaded 2022-11-28	Repair queued
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	Missing upstream

IC Document Collections

IC ID	Collection	Type	Status	Form
270333	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv)	Form and Instruction	New
270333	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv)	Form and Instruction	New
270316	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv)	Form and Instruction	New
270316	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv)	Form and Instruction	New
270313	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv)	Form and Instruction	New
270313	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv)	Form and Instruction	New
270312	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual)	Form and Instruction	New
270312	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual)	Form and Instruction	New
270310	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv)	Form and Instruction	New
270310	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv)	Form and Instruction	New
270309	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)	Form and Instruction	New
270309	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)	Form and Instruction	New
269868	57.102 - Hospital Respiratory Data Fomr (Daily - API)	Form and Instruction	Unchanged
269868	57.102 - Hospital Respiratory Data Fomr (Daily - API)	Form and Instruction	Unchanged
269867	57.102 Hospital Respiratory Data Form (Daily - .csv import)	Form and Instruction	Unchanged
269867	57.102 Hospital Respiratory Data Form (Daily - .csv import)	Form and Instruction	Unchanged
269866	57.102 - Hospital Respiratory Data Form (Daily - user entry)	Form and Instruction	Unchanged
269866	57.102 - Hospital Respiratory Data Form (Daily - user entry)	Form and Instruction	Unchanged
269865	57.101 Hospital Respiratory Data Form (Weekly - API)	Form and Instruction	Unchanged
269865	57.101 Hospital Respiratory Data Form (Weekly - API)	Form and Instruction	Unchanged
269864	57.101 Hospital Respiratory Data Form (Weekly - .csv import)	Form and Instruction	Unchanged
269864	57.101 Hospital Respiratory Data Form (Weekly - .csv import)	Form and Instruction	Unchanged
269863	57.101 Hospital Respiratory Data Form (Weekly - User Entry)	Form and Instruction	Unchanged
269863	57.101 Hospital Respiratory Data Form (Weekly - User Entry)	Form and Instruction	Unchanged
266012	Point of Care Testing Results	Form and Instruction	Unchanged
266012	Point of Care Testing Results	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
257194	NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs)	Form and Instruction	Unchanged
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 (manual)	Form and Instruction	Modified
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual)	Form and Instruction	Modified
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual)	Form and Instruction	Modified
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual)	Form and Instruction	Modified
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

OMB Control No: 0920-1317	ICR Reference No: 202408-0920-011
Status: Active	Previous ICR Reference No: 202407-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1317-24IH
Title: [NCEZID] National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/23/2024
	Date Received in OIRA: 08/22/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2026	03/31/2026	03/31/2026
Responses	6,086,324	0	8,295,144
Time Burden (Hours)	2,766,084	0	4,426,312
Cost Burden (Dollars)	0	0	0

---

Abstract: The goal of this information collection is to 1) capture the daily, aggregate impact of COVID-19 on healthcare facilities, and 2) monitor medical capacity to respond at local, state, and national levels. This information will be used to inform the overall real-time COVID-19 response efforts and possible resource allocation, and enable state and local health departments to gain immediate access to the COVID-19 data for healthcare facilities within their jurisdiction. This Change Request is submitted to add two new data collection forms and revisions to two currently approved data collection instruments. There is a net decrease in burden hours.

---

Authorizing Statute(s): US Code: 42 USC 242b, k, m Name of Law: The Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 55815	09/12/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 73309	11/29/2022
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 31

IC Title	Form No.	Form Name
57.101 Hospital Respiratory Data Form (Weekly - .csv import)	0920-1317	Hospital Respiratory Data Weekly Reporting Form
57.101 Hospital Respiratory Data Form (Weekly - API)	0920-1317	Hospital Respiratory Data Weekly Reporting Form
57.101 Hospital Respiratory Data Form (Weekly - User Entry)	0920-1317	Hospital Respiratory Data Weekly Reporting Form
57.102 - Hospital Respiratory Data Fomr (Daily - API)	57.102	Hospital Respiratory Data Daily Reporting Form 14AUG2024
57.102 - Hospital Respiratory Data Form (Daily - user entry)	57.102	Hospital Respiratory Data Daily Reporting Form 14AUG2024
57.102 Hospital Respiratory Data Form (Daily - .csv import)	57.102	Hospital Respiratory Data Daily Reporting Form 14AUG2024
Dialysis Component	n/a	COVID–19 Module - Dialysis Outpatient Facility
Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	CDC Form 57.203	Healthcare Personnel Safety Monthly Reporting Plan
Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities	CDC Form 57.203	Healthcare Personnel Safety Monthly Reporting Plan
Long Term Care Facility Resident Impact and Facility Capacity Pathway	57.144, CDC 57.144	Resident Impact and Facility Capacity ,   COVID-19 and Respiratory Infections Module Long Term Care Facility Resident Impact and Facility Capacity Pathway Form (57.144) 07SEP2023
Monthly Reporting Plan form for Long-term Care Facilities	CDC Form 57.141	Monthly Reporting Plan for LTCF
NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs)	n/a	NHSN COVID-19 Hospital Module Infusion Centers and Outpatient Clinics
NHSN and Secure Access Management Services (SAMS) enrollment	0920-1317	NHSN Registration Form
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv)	57.217	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual)	57.217	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv)	57.216	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)	57.216	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents
Point of Care Testing Results	57.155	Point of Care Testing Results
Staff and Personnel Impact - Business and Financial Operations Occupations	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - Business and Financial Operations Occupations retrospective	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel retrospective	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations retrospective	CDC 57.145	Staff and Personnel Impact
VA - Resident COVID-19 Event Form - LTCF	0920-1317	VA COVID-19 Resident Event Form
VA - Staff and Personnel COVID-19 Event Form - LTCF	0920-1317	VA - Staff and Personnel COVID-19 Event Form
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv)	57.219	Healthcare Personnel COVID-19 Vaccination Cumulative Summary
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual)	57.219	Healthcare Personnel COVID-19 Vaccination Cumulative Summary
Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	0920-1317 / CDC Form 57.509	Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv)	57.218	Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual)	57.218	Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	6,086,324	8,295,144	0	-2,208,820	0	0
Annual Time Burden (Hours)	2,766,084	4,426,312	0	-1,660,228	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Two forms were added and respondent numbers were adjusted for one form.

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/22/2024

---