Information Collection Request

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

ICR 202501-0920-003 · OMB 0920-1317 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility-.csv Form and Instruction Unchanged Available
Form 57.509 57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_CSV Form and Instruction Unchanged Available
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV Form and Instruction Unchanged Available
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_Manual Form and Instruction Unchanged Available
Form 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_CSV Form and Instruction Unchanged Available
Form 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_Manual Form and Instruction Unchanged Available
Form 57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_CSV Form and Instruction Unchanged Available
Form 57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_Manual Form and Instruction Unchanged Available
Form 57.155 Point of Care Testing Results Form and Instruction Unchanged Available
Form 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction Unchanged Available
Form 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (.csv) Form and Instruction Modified Available
Form 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities Form and Instruction Modified Available
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel Form and Instruction Unchanged Available
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel Form and Instruction Unchanged Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form and Instruction Unchanged Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form and Instruction Unchanged Available
Form 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024 Form and Instruction Unchanged Available
Form 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024 Form and Instruction Unchanged Available
Form 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024 Form and Instruction Unchanged Available
Form 0920-1317 Hospital Respiratory Data Weekly Reporting Form Form and Instruction Unchanged Available
Form 0920-1317 Hospital Respiratory Data Weekly Reporting Form Form and Instruction Unchanged Available
Form 0920-1317 Hospital Respiratory Data Weekly Reporting Form Form and Instruction Unchanged Available
Form 57.155 Point of Care Testing Results Form and Instruction Unchanged Available
Form 57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_Manual Form and Instruction Unchanged Available
Form 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (manual) Form and Instruction Modified Available
Form Form 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities (manual) Form and Instruction Modified Available
Form 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction Unchanged Repair queued
Form 57.510 COVID–19 Module - Dialysis Outpatient Facility Form and Instruction Unchanged Available
Form 0920-1317 NHSN Registration Form Form and Instruction Unchanged Available
Change Memo 0920-1317 December 2024.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-01-09 Available
D. Explanation for Program Changes or Adjustments.docx Supplementary Document Uploaded 2024-10-29 Available
G2. Privacy Impact Assessment.pdf Supplementary Document Uploaded 2024-10-29 Available
G1. Privacy Impact Assessment.pdf Supplementary Document Uploaded 2024-10-29 Available
G. Privacy Impact Assessment.pdf Supplementary Document Uploaded 2024-10-29 Available
E3. Human Subjects Determination.pdf Supplementary Document Uploaded 2024-10-29 Available
B. FRN-60 day.pdf Supplementary Document Uploaded 2024-10-29 Available
SSB 0920-1317 NHSN COVID-19_FINAL.docx Supporting Statement B Uploaded 2024-10-29 Available
SSA 0920-1317 NHSN COVID 08JAN2025.docx Supporting Statement A Uploaded 2025-01-08 Available
Change Memo 0920-1317 August 2024_FINAL_v2.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-08-22 Available
Change Memo 0920-1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-08-06 Available
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-04-26 Available
Change Memo for CDC NHSN COVID-19 OMB Package 0920-1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-03-14 Available
Resident Impact and Facility Capacity- csv temp..csv 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 Available
Change Memo for NHSN September 2023_0920_1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2023-09-07 Available
Crosswalk_57.218.docx Supplementary Document Uploaded 2023-09-07 Available
Crosswalk_57.144.docx Supplementary Document Uploaded 2023-09-07 Available
Crosswalk-COVID-19 Hospital Data.docx Supplementary Document Uploaded 2023-09-07 Available
Crosswalk 11.4 updated COVID JUNE_final.docx Supplementary Document 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 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
6. IRB Protocol Closure.pdf Supplementary Document Uploaded 2022-11-28 Available
3. Privacy Act Checklist 2022.docx Supplementary Document Uploaded 2022-11-28 Repair queued
1c. 42 USC 242m.PDF Supplementary Document Uploaded 2022-11-28 Available
1b. 42 USC 242k.PDF Supplementary Document Uploaded 2022-11-28 Available
1a. 42 USC 242b.PDF Supplementary Document Uploaded 2022-11-28 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
271955 57.510 COVID–19 Module Dialysis Outpatient Facility-CSV Form and Instruction Unchanged57.510 COVID–19 Module Dialysis Outpatient Facility-.csv
271950 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV Form and Instruction Unchanged57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_CSV
271948 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV Form and Instruction Unchanged57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV
271947 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_Manual Form and Instruction Unchanged57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_Manual
271946 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_CSV Form and Instruction UnchangedHealthcare Personnel COVID-19 Person Level Vaccination-LTC Component_CSV
271945 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component _Manual Form and Instruction UnchangedHealthcare Personnel COVID-19 Person Level Vaccination-LTC Component_Manual
271943 57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_CSV Form and Instruction UnchangedWeekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_CSV
271941 57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_Manual Form and Instruction UnchangedWeekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_Manual
271935 57.155 Point of Care Testing Results - CSV Form and Instruction UnchangedPoint of Care Testing Results
270333 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) Form and Instruction UnchangedHealthcare Personnel COVID-19 Vaccination Cumulative Summary
270316 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction ModifiedWeekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (.csv)
270316 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction ModifiedWeekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities
270313 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv) Form and Instruction UnchangedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel
270312 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) Form and Instruction UnchangedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel
270310 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv) Form and Instruction UnchangedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents
270309 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual) Form and Instruction UnchangedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents
269868 57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction UnchangedHospital Respiratory Data Daily Reporting Form 14AUG2024
269867 57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction UnchangedHospital Respiratory Data Daily Reporting Form 14AUG2024
269866 57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction UnchangedHospital Respiratory Data Daily Reporting Form 14AUG2024
269865 57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction UnchangedHospital Respiratory Data Weekly Reporting Form
269864 57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction UnchangedHospital Respiratory Data Weekly Reporting Form
269863 57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction UnchangedHospital Respiratory Data Weekly Reporting Form
266012 57.155 Point of Care Testing Results - Manual Form and Instruction UnchangedPoint of Care Testing Results
249436 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual Form and Instruction UnchangedWeekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_Manual
249435 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction ModifiedWeekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (manual)
249435 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction ModifiedWeekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities (manual)
249434 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) Form and Instruction UnchangedHealthcare Personnel COVID-19 Vaccination Cumulative Summary
243719 57.510 COVID–19 Module Dialysis Outpatient Facility_Manual Form and Instruction UnchangedCOVID–19 Module - Dialysis Outpatient Facility
243698 57.140 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction UnchangedNHSN Registration Form

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
01/31/2028 01/31/2028 01/31/2028
3,557,181 0 3,653,433
1,731,823 0 1,752,540
0 0 0





Reginfo record details
27
table that charts list of burden
IC Title Form No. Form Name
57.101 Hospital Respiratory Data Form (Weekly - .csv import) 0920-1317
57.101 Hospital Respiratory Data Form (Weekly - API) 0920-1317
57.101 Hospital Respiratory Data Form (Weekly - User Entry) 0920-1317
57.102 - Hospital Respiratory Data Fomr (Daily - API) 57.102
57.102 - Hospital Respiratory Data Form (Daily - user entry) 57.102
57.102 Hospital Respiratory Data Form (Daily - .csv import) 57.102
57.140 NHSN and Secure Access Management Services (SAMS) enrollment 0920-1317
57.155 Point of Care Testing Results - CSV 57.155
57.155 Point of Care Testing Results - Manual 57.155
57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_CSV 57.220
57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_Manual 57.220
57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV 57.221
57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_Manual 57.221
57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component _Manual 57.221
57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_CSV 57.221
57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV 57.509
57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual 57.509
57.510 COVID–19 Module Dialysis Outpatient Facility-CSV 57.510
57.510 COVID–19 Module Dialysis Outpatient Facility_Manual 57.510
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 (manual) 57.217
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 (manual) 57.216
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) 57.219
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) 57.219
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) 57.218, 57.218 ,  
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) 57.218, Form 57.218 ,  

table that charts list 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 3,557,181 3,653,433 0 -96,252 0 0
Annual Time Burden (Hours) 1,731,823 1,752,540 0 -20,717 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No