OMB control number

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

OMB 0920-1306 · HHS/CDC.

OMB 0920-1306

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Dialysis Facility Infection Preventionists - NHSN New Facility Enrollment	Form
Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form	Form
Form 57.145 State and Local Health Department occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	Form
Form 57.145 Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	Form and Instruction
Form 57.145 LTCF - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	Form
Form 57.145 State and Local Health Department occupations -Staff and Personnel Impact form (57.145)	Form
Form 57.145 Business and Financial Operations occupations - Staff and Personnel Impact form (57.145)	Form
Form 57.145 LTCF - Staff and Personnel Impact form (57.145)	Form
Form 57.144 State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Datat Entry	Form
Form 57.144 Business and Financial Operations occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry	Form
Form 57.144 LTCF Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry	Form
Form 57.144 State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144)	Form
Form 57.144 Business and Financial Operations Occupations - Resident Impact and Facility Capacity form (57.144)	Form
Form 57.144 LTCF Personnel - Resident Impact and Facility Capacity form (57.144)	Form
Form 57.155 NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel	Form and Instruction
0920-1306 Change Memo - NHSN COVID-19 LTCF_11.10.20.docx	Justification for No Material/Nonsubstantive Change
0920-1290 Change Memo - NHSN COVID-19 LTCF_10 15 20.docx	Justification for No Material/Nonsubstantive Change
Revised SSB 15OCT2020.docx	Supporting Statement B
Revised SSA 15OCT2020.docx	Supporting Statement A
Revised Emergency Request Memo 15OCT2020.docx	Supplementary Document
Dialysis Facility Infection Preventionists - NHSN New Facility Enrollment	Form
Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form	Form
State and Local Health Department occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	Form
Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	Form and Instruction
LTCF - Staff and Personnel Impact form (57.145) - Retrospective Data Entry	Form
State and Local Health Department occupations -Staff and Personnel Impact form (57.145)	Form
Business and Financial Operations occupations - Staff and Personnel Impact form (57.145)	Form
LTCF - Staff and Personnel Impact form (57.145)	Form
State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Datat Entry	Form
Business and Financial Operations occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry	Form
LTCF Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry	Form
State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144)	Form
Business and Financial Operations Occupations - Resident Impact and Facility Capacity form (57.144)	Form
LTCF Personnel - Resident Impact and Facility Capacity form (57.144)	Form
NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel	Form and Instruction

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Concluded	Action
202011-0920-005	No material or nonsubstantive change to a currently approved collection	2020-11-11		Approved with change
202010-0920-008	New collection (Request for a new OMB Control Number)	2020-10-15		Approved with change