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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility-.csv	Form and Instruction	Unchanged	Repair queued
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility-CSV	Form and Instruction	Unchanged	Repair queued
Form 57.509 57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_CSV	Form and Instruction	Unchanged	Available
Form 57.509 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV	Form and Instruction	Unchanged	Repair queued
Form 57.155 Point of Care Testing Results	Form and Instruction	Unchanged	Available
Form 57.155 57.155 Point of Care Testing Results - CSV	Form and Instruction	Unchanged	Repair queued
Form 57.219 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary_25SEP2025	Form and Instruction	Modified	Available
Form 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary	Form and Instruction	Modified	Available
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv)	Form and Instruction	Modified	Repair queued
Form 57.218 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025	Form and Instruction	Modified	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 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv)	Form and Instruction	Modified	Repair queued
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel 29SEP2025	Form and Instruction	Modified	Available
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel	Form and Instruction	Modified	Available
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv)	Form and Instruction	Modified	Missing upstream
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel_29SEP2025	Form and Instruction	Modified	Available
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel	Form and Instruction	Modified	Available
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual)	Form and Instruction	Modified	Repair queued
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form 57.216_rev 29SEP2025	Form and Instruction	Modified	Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents	Form and Instruction	Modified	Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv)	Form and Instruction	Modified	Missing upstream
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form 57.216_rev 29SEP2025	Form and Instruction	Modified	Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents	Form and Instruction	Modified	Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)	Form and Instruction	Modified	Repair queued
Form 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024	Form and Instruction	Unchanged	Available
Form 57.102 57.102 - Hospital Respiratory Data Fomr (Daily - API)	Form and Instruction	Unchanged	Repair queued
Form 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024	Form and Instruction	Unchanged	Available
Form 57.102 57.102 Hospital Respiratory Data Form (Daily - .csv import)	Form and Instruction	Unchanged	Repair queued
Form 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024	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 Hospital Respiratory Data Weekly Reporting Form	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 Hospital Respiratory Data Weekly Reporting Form	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 Hospital Respiratory Data Weekly Reporting Form	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 57.155 Point of Care Testing Results - Manual	Form and Instruction	Unchanged	Repair queued
Form 57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_Manual	Form and Instruction	Unchanged	Available
Form 57.509 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual	Form and Instruction	Unchanged	Repair queued
Form 57.218 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025	Form and Instruction	Modified	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 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 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary	Form and Instruction	Modified	Available
Form 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary	Form and Instruction	Modified	Available
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual)	Form and Instruction	Modified	Repair queued
Form 57.510 COVID–19 Module - Dialysis Outpatient Facility	Form and Instruction	Unchanged	Available
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility_Manual	Form and Instruction	Unchanged	Repair queued
Form 0920-1317 NHSN Registration Form	Form and Instruction	Unchanged	Available
Form 0920-1317 57.140 NHSN and Secure Access Management Services (SAMS) enrollment	Form and Instruction	Unchanged	Repair queued
Change Memo 0920-1317 September 2025 FINAL_30SEP2025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-09-30	Available
Change Memo 0920-1317 September 2025 FINAL_30SEP2025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-09-30	Repair queued
Change Request Memo - EO14168.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-04	Available
Change Request Memo - EO14168.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-04	Repair queued
Change Memo 0920-1317 December 2024.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-01-09	Available
Change Memo 0920-1317 December 2024.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-01-09	Missing upstream
D. Explanation for Program Changes or Adjustments.docx	Supplementary Document	Uploaded 2024-10-29	Available
D. Explanation for Program Changes or Adjustments.docx	Supplementary Document	Uploaded 2024-10-29	Repair queued
G2. Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2024-10-29	Available
G2. Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2024-10-29	Repair queued
G1. Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2024-10-29	Available
G1. Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2024-10-29	Repair queued
G. Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2024-10-29	Available
G. Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2024-10-29	Repair queued
E3. Human Subjects Determination.pdf	Supplementary Document	Uploaded 2024-10-29	Available
E3. Human Subjects Determination.pdf	Supplementary Document	Uploaded 2024-10-29	Repair queued
B. FRN-60 day.pdf	Supplementary Document	Uploaded 2024-10-29	Available
B. FRN-60 day.pdf	Supplementary Document	Uploaded 2024-10-29	Repair queued
SSB 0920-1317 NHSN COVID-19_FINAL.docx	Supporting Statement B	Uploaded 2024-10-29	Available
SSB 0920-1317 NHSN COVID-19_FINAL.docx	Supporting Statement B	Uploaded 2024-10-29	Repair queued
SSA 0920-1317 NHSN COVID 08JAN2025.docx	Supporting Statement A	Uploaded 2025-03-04	Available
SSA 0920-1317 NHSN COVID 08JAN2025.docx	Supporting Statement A	Uploaded 2025-03-04	Repair queued
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	Missing upstream
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-04-26	Available
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-04-26	Repair queued
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	Available
Resident Impact and Facility Capacity- csv temp..csv	Supplementary Document	Uploaded 2023-09-07	Available
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	Missing upstream
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	Repair queued
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	Repair queued
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
1c. 42 USC 242m.PDF	Supplementary Document	Uploaded 2022-11-28	Available
1c. 42 USC 242m.PDF	Supplementary Document	Uploaded 2022-11-28	Missing upstream
1b. 42 USC 242k.PDF	Supplementary Document	Uploaded 2022-11-28	Available
1b. 42 USC 242k.PDF	Supplementary Document	Uploaded 2022-11-28	Repair queued
1a. 42 USC 242b.PDF	Supplementary Document	Uploaded 2022-11-28	Available
1a. 42 USC 242b.PDF	Supplementary Document	Uploaded 2022-11-28	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
271955	57.510 COVID–19 Module Dialysis Outpatient Facility-CSV	Form and Instruction	Unchanged	57.510 COVID–19 Module Dialysis Outpatient Facility-.csv
271955	57.510 COVID–19 Module Dialysis Outpatient Facility-CSV	Form and Instruction	Unchanged
271950	57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV	Form and Instruction	Unchanged	57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_CSV
271950	57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV	Form and Instruction	Unchanged
271935	57.155 Point of Care Testing Results - CSV	Form and Instruction	Unchanged	Point of Care Testing Results
271935	57.155 Point of Care Testing Results - CSV	Form and Instruction	Unchanged
270333	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv)	Form and Instruction	Modified	57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary_25SEP2025
270333	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv)	Form and Instruction	Modified	Healthcare Personnel COVID-19 Vaccination Cumulative Summary
270333	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv)	Form and Instruction	Modified
270316	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv)	Form and Instruction	Modified	57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025
270316	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv)	Form and Instruction	Modified	Weekly 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	Modified	Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities
270316	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv)	Form and Instruction	Modified
270313	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv)	Form and Instruction	Modified	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel 29SEP2025
270313	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv)	Form and Instruction	Modified	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel
270313	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv)	Form and Instruction	Modified
270312	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual)	Form and Instruction	Modified	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel_29SEP2025
270312	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual)	Form and Instruction	Modified	Optional 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	Modified
270310	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv)	Form and Instruction	Modified	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form 57.216_rev 29SEP2025
270310	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv)	Form and Instruction	Modified	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents
270310	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv)	Form and Instruction	Modified
270309	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)	Form and Instruction	Modified	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form 57.216_rev 29SEP2025
270309	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)	Form and Instruction	Modified	Optional 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	Modified
269868	57.102 - Hospital Respiratory Data Fomr (Daily - API)	Form and Instruction	Unchanged	Hospital Respiratory Data Daily Reporting Form 14AUG2024
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	Hospital Respiratory Data Daily Reporting Form 14AUG2024
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	Hospital Respiratory Data Daily Reporting Form 14AUG2024
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	Hospital Respiratory Data Weekly Reporting Form
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	Hospital Respiratory Data Weekly Reporting Form
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	Hospital Respiratory Data Weekly Reporting Form
269863	57.101 Hospital Respiratory Data Form (Weekly - User Entry)	Form and Instruction	Unchanged
266012	57.155 Point of Care Testing Results - Manual	Form and Instruction	Unchanged	Point of Care Testing Results
266012	57.155 Point of Care Testing Results - Manual	Form and Instruction	Unchanged
249436	57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual	Form and Instruction	Unchanged	Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_Manual
249436	57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual	Form and Instruction	Unchanged
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual)	Form and Instruction	Modified	57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual)	Form and Instruction	Modified	Weekly 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	Modified	Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities (manual)
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	57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual)	Form and Instruction	Modified	Healthcare Personnel COVID-19 Vaccination Cumulative Summary
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual)	Form and Instruction	Modified
243719	57.510 COVID–19 Module Dialysis Outpatient Facility_Manual	Form and Instruction	Unchanged	COVID–19 Module - Dialysis Outpatient Facility
243719	57.510 COVID–19 Module Dialysis Outpatient Facility_Manual	Form and Instruction	Unchanged
243698	57.140 NHSN and Secure Access Management Services (SAMS) enrollment	Form and Instruction	Unchanged	NHSN Registration Form
243698	57.140 NHSN and Secure Access Management Services (SAMS) enrollment	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-1317	ICR Reference No: 202509-0920-004
Status: Active	Previous ICR Reference No: 202502-0920-015
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-25-0176
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: 02/10/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/30/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2028	01/31/2028	01/31/2028
Responses	3,323,021	0	3,381,437
Time Burden (Hours)	1,558,384	0	1,585,369
Cost Burden (Dollars)	0	0	0

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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 for 0920-01317 to update forms, following revised ACIP vaccine recommendations for COVID-19. There is a net decrease in burden hours associated with this Change Request.

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 47962	06/04/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 84146	10/21/2024
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 21

table that charts list of burden

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
57.140 NHSN and Secure Access Management Services (SAMS) enrollment	0920-1317	NHSN Registration Form
57.155 Point of Care Testing Results - CSV	57.155	Point of Care Testing Results
57.155 Point of Care Testing Results - Manual	57.155	Point of Care Testing Results
57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV	57.509	57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_CSV
57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual	57.509	Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_Manual
57.510 COVID–19 Module Dialysis Outpatient Facility-CSV	57.510	57.510 COVID–19 Module Dialysis Outpatient Facility-.csv
57.510 COVID–19 Module Dialysis Outpatient Facility_Manual	57.510	COVID–19 Module - Dialysis Outpatient Facility
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv)	57.217, 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 29SEP2025
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual)	57.217, 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_29SEP2025
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv)	57.216, 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 Form 57.216_rev 29SEP2025
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)	57.216, 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 Form 57.216_rev 29SEP2025
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv)	57.219, 57.219	Healthcare Personnel COVID-19 Vaccination Cumulative Summary ,   57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary_25SEP2025
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual)	57.219, 57.219	Healthcare Personnel COVID-19 Vaccination Cumulative Summary ,   57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv)	57.218, 57.218, 57.218	Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities ,   Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (.csv) ,   57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual)	57.218, Form 57.218, 57.218	Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities (manual) ,   Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (manual) ,   57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025

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ICR Summary of Burden

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	3,323,021	3,381,437	0	-58,416	0	0
Annual Time Burden (Hours)	1,558,384	1,585,369	0	-26,985	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: Change Request for 0920-1317 includes modifications to four (4) forms. There is a net decrease in overall burden.

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Annual Cost to Federal Government: $49,992,135

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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

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Common Form ICR:  No

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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: 09/30/2025

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