OMB control number

National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities

OMB 0920-1290 · HHS/CDC.

OMB 0920-1290

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 hospitals within their jurisdiction. Information collection for long term care facilities are being added to this request. This Change Request is requested by the White House Coronavirus Task Force, and is submitted to add data elements to the Patient Impact and Hospital Capacity form in order to strengthen the COVID-19 response efforts.

The latest form for National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities expires 2020-09-30 and is listed under ICR 202005-0920-014.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form 0920-1290 TeleTracking (TT) - U.S. HealthCare COVID-19 Portal	Form and Instruction
Form 0920-1290 State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry)	Form and Instruction
Form 0920-1290 Business and Financial Operations Occupations - Resident Impact/Facility Capacity Form - Retrospective Data Entry	Form and Instruction
Form 0920-1290 LTCF Personnel - Resident Impact/Facility Capacity - Retrospective Data Entry	Form and Instruction
Form 0920-1290 State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry	Form and Instruction
Form 0920-1290 Business and Financial Operations Occupations - Staff and Personnel Impact - Retrospective Data Entry	Form and Instruction
Form 0920-1290 LTCF Personnel - Staff and Personnel Impact - Retrospective Data Entry	Form and Instruction
Form 0920-1290 NHSN and Secure Access Management Services (SAMS) Enrollment	Form and Instruction
LTC Supplies and PPE - state/local health depts.	Form
LTC Supplies and PPE - business operations occupations	Form
LTC Supplies and PPE - microbiologists	Form
LTC Ventilator Capacity - state/local health depts.	Form
LTC Ventilator Capacity - business operations occupations	Form
LTC Ventilator Capacity - microbiologists	Form
LTCF Resident Impact and Facitlity Capacity - State/Local Health Department Occupations.	Form
LTCF Resident Impact and Facitlity Capacity - Business and Financial Operations Occupations	Form
LTCF Resident Impact and Facility Capacity - LTCF personnel	Form
LTC Staff and Personnel Impact - state/local health depts.	Form
LTC Staff and Personnel Impact - business operations occupations	Form
LTC Staff and Personnel Impact - microbiologist	Form
Form 0920-1290 COVID-19 Supplies Form - State and Local Health Department	Form and Instruction
Form 0920-1290 COVID-19 Supplies Form - Business/Financial Operations	Form and Instruction
Form 0920-1290 COVID-19 Supplies Form - Microbiologist	Form and Instruction
Form 0920-1290 COVID-19 Healthcare Worker Form - State and Local Health Department	Form and Instruction
Form 0920-1290 COVID-19 Healthcare Worker Form - Business/Financial Operations	Form and Instruction
Form 0920-1290 COVID-19 Healthcare Worker Form - Microbiologist	Form and Instruction
COVID-19 Patient Impact Module Form - State and Local Health Departments	Form
COVID-19 Patient Impact Module Form - Business/Financial Operations	Form
COVID-19 Patient Impact Module Form - Microbiologist	Form
Change Request Memo 20AUG2020.docx	Justification for No Material/Nonsubstantive Change
0920-1290 Change Memo - NHSN COVID-19 LTCF_7-23-20.docx	Justification for No Material/Nonsubstantive Change
0920-1290 Change Memo - NHSN COVID-19 supply changes 02JUL2020 FINAL.docx	Justification for No Material/Nonsubstantive Change
0920-1290 Change Memo - NHSN COVID-19 PIHC changes 05292020.docx	Justification for No Material/Nonsubstantive Change
0920-1290 Change Memo - NHSN COVID-19 PIHC changes 050820.docx	Justification for No Material/Nonsubstantive Change
3. Upcoming Additional and Modified Fields for Acute Care COVID-19 Module.pdf	Supplementary Document
4. BlastEmail_ allPSFacs for Friday morn_DRAFT_ (002) clean.docx	Supplementary Document
Change Request Memo 07MAY2020.docx	Justification for No Material/Nonsubstantive Change
CDC 57.145_TOI_Staff and Personnel Impact (OMB)_6May2020_FINAL.docx	Supplementary Document
CDC 57.144_TOI_Resident Impact and Facility Capacity (OMB)_6May2020_FINAL.docx	Supplementary Document
Change Request Memo 07MAY2020.docx	Justification for No Material/Nonsubstantive Change
CDC 57.147_TOI_Ventilator Capacity and Supplies.docx	Supplementary Document
CDC 57.146 TOI_Supplies and Personal Protective Equipment.docx	Supplementary Document
0920-1290 Change Memo - NHSN COVID-19 LTCF_4-30-20.docx	Justification for No Material/Nonsubstantive Change
Supporting Statement A NHSN COVID-19_042220 clean.docx	Supporting Statement A
0920-1290 Change Request- NHSN COVID-19 LTCF_4-22-20 clean.docx	Justification for No Material/Nonsubstantive Change
HDCommunication FINAL 10APR2020.docx	Supplementary Document
0920-1290 Change Request- NHSN COVID-19 Module 04092020.docx	Justification for No Material/Nonsubstantive Change
Att4c_How to Enter and Access COVID Summary Data.docx	Supplementary Document
Revised Emergency Request Memo 23MAR2020.docx	Supplementary Document
Att6_NHSN Report of End of Human Research Review.docx	Supplementary Document
Att5_Closure of CDC Protocol 4062.docx	Supplementary Document
Att1c_42 USC 242m.pdf	Supplementary Document
Att1b_42 USC 242k.pdf	Supplementary Document
Att1a_42 USC 242b.pdf	Supplementary Document
Att3_PIA.pdf	Supplementary Document
Supporting Statement B NHSN COVID-19_clean.docx	Supporting Statement B
TeleTracking (TT) - U.S. HealthCare COVID-19 Portal	Form and Instruction
State and Local Health Department - Resident Impact / Facility Capacity Form (Retrospective Datat Entry)	Form and Instruction
Business and Financial Operations Occupations - Resident Impact/Facility Capacity Form - Retrospective Data Entry	Form and Instruction
LTCF Personnel - Resident Impact/Facility Capacity - Retrospective Data Entry	Form and Instruction
State and Local Health Departments - Staff and Personnel Impact - Retrospective Data Entry	Form and Instruction
Business and Financial Operations Occupations - Staff and Personnel Impact - Retrospective Data Entry	Form and Instruction
LTCF Personnel - Staff and Personnel Impact - Retrospective Data Entry	Form and Instruction
NHSN and Secure Access Management Services (SAMS) Enrollment	Form and Instruction
LTC Supplies and PPE - state/local health depts.	Form
LTC Supplies and PPE - business operations occupations	Form
LTC Supplies and PPE - microbiologists	Form
LTC Ventilator Capacity - state/local health depts.	Form
LTC Ventilator Capacity - business operations occupations	Form
LTC Ventilator Capacity - microbiologists	Form
LTCF Resident Impact and Facitlity Capacity - State/Local Health Department Occupations.	Form
LTCF Resident Impact and Facitlity Capacity - Business and Financial Operations Occupations	Form
LTCF Resident Impact and Facility Capacity - LTCF personnel	Form
LTC Staff and Personnel Impact - state/local health depts.	Form
LTC Staff and Personnel Impact - business operations occupations	Form
LTC Staff and Personnel Impact - microbiologist	Form
COVID-19 Supplies Form - State and Local Health Department	Form and Instruction
COVID-19 Supplies Form - Business/Financial Operations	Form and Instruction
COVID-19 Supplies Form - Microbiologist	Form and Instruction
COVID-19 Healthcare Worker Form - State and Local Health Department	Form and Instruction
COVID-19 Healthcare Worker Form - Business/Financial Operations	Form and Instruction
COVID-19 Healthcare Worker Form - Microbiologist	Form and Instruction
COVID-19 Patient Impact Module Form - State and Local Health Departments	Form
COVID-19 Patient Impact Module Form - Business/Financial Operations	Form
COVID-19 Patient Impact Module Form - Microbiologist	Form

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202008-0920-012	No material or nonsubstantive change to a currently approved collection	2020-08-26	Approved with change
202007-0920-017	No material or nonsubstantive change to a currently approved collection	2020-07-30	Approved with change
202007-0920-005	No material or nonsubstantive change to a currently approved collection	2020-07-02	Approved with change
202006-0920-014	No material or nonsubstantive change to a currently approved collection	2020-07-01	Withdrawn and continue
202005-0920-014	No material or nonsubstantive change to a currently approved collection	2020-05-30	Approved with change
202005-0920-008	No material or nonsubstantive change to a currently approved collection	2020-05-14	Approved with change
202005-0920-004	No material or nonsubstantive change to a currently approved collection	2020-05-08	Approved with change
202005-0920-001	No material or nonsubstantive change to a currently approved collection	2020-05-04	Approved with change
202004-0920-017	No material or nonsubstantive change to a currently approved collection	2020-04-23	Approved with change
202004-0920-004	No material or nonsubstantive change to a currently approved collection	2020-04-10	Approved with change
202003-0920-015	New collection (Request for a new OMB Control Number)	2020-03-24	Approved with change

OMB Details

COVID-19 Patient Impact Module Form - Microbiologist

Federal Enterprise Architecture: Health - Public Health Monitoring

Information collection instruments
Form	Name	Electronic access	Type
Form NA	COVID-19 Patient Impact Module Form	NA	Form
Form 00920-1290	COVID-19 Patient Impact Module Form 29MAY2020	NA	Form
Form 0920-1290	COVID-19 Patient Impact Module Form - 14MAY2020	NA	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.