Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Dialysis Component Modified 800800 333667 0 Form and Instruction 0920-20LW Dialysis Component
Form and Instruction 0920-1317 COVID-19 Module Dialysis Outpatient Facility
Form and Instruction 0920-1317 COVID-19 Module Dialysis Outpatient Facility Form 27MAY2021
Form and Instruction 0920-1317 / Form 57.510 COVID–19 Module - Dialysis Outpatient Facility
Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities New 69300 5775 0 Form and Instruction 0920-1317 / CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan
Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities New 4728 394 0 Form and Instruction 0920-1317 / CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan
Monthly Reporting Plan form for Long-term Care Facilities New 151776 12648 0 Form and Instruction 0920-1317 / CDC Form 57.141 Monthly Reporting Plan for LTCF
NHSN and Secure Access Management Services (SAMS) enrollment Unchanged 11500 11500 0 Form and Instruction 0920-20LW NHSN Registration Form
Resident Impact and Facility Capacity - Business and Financial Operations Occupations Unchanged 97240 72930 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Form and Instruction 0920-1317 CDC 57.144 Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective Unchanged 935 623 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - LTCF Personnel Modified 858624 858624 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Form and Instruction 0920-1317 CDC 57.144 Resident Impact and Facility Capacity
Form and Instruction 0920-1317 Form 57.144 Resident Impact and Facility Capacity Form 21SEP2021
Resident Impact and Facility Capacity - LTCF Personnel retrospective Unchanged 5811 3874 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - State and Local Health Dept Occupations Unchanged 97240 72930 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Form and Instruction 0920-1317 CDC 57.144 Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective Unchanged 935 623 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Resident Therapeutics - Business and Financial Operations Occupations Unchanged 97240 16207 0 Form and Instruction 0920-1317 CDC 57.XXX Long Term Care Facility: Resident Therapeutics
Resident Therapeutics - LTCF Personnel Modified 858624 143104 0 Form and Instruction 0920-1317 CDC 57.XXX Long-Term Care Facility: Resident Therapeutics
Resident Therapeutics - State and Local Health Dept. Occupations Unchanged 97240 16207 0 Form and Instruction 0920-1317 CDC 57.XXX Long Term Care Facility: Resident Therapeutics
Staff and Personnel Impact - Business and Financial Operations Occupations Unchanged 97240 24310 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Unchanged 935 234 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel Unchanged 604292 151073 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel retrospective Unchanged 5811 1453 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations Unchanged 97240 24310 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Unchanged 935 234 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Supplies & Personal Protective Equipment - Business and Financial Operations Occupations Unchanged 97240 40517 0 Form and Instruction CDC 57.146 Supplies & Personal Protective Equipment
Form and Instruction CDC 57.146 COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
Supplies & Personal Protective Equipment - LTCF Personnel Unchanged 604292 251788 0 Form and Instruction CDC 57.146 Supplies & Personal Protective Equipment
Form and Instruction CDC 57.146 COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
Supplies & Personal Protective Equipment - State and Local Health Dept Occupations Unchanged 97240 40517 0 Form and Instruction CDC 57.146 Supplies & Personal Protective Equipment
Form and Instruction CDC 57.146 COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
VA - Resident COVID-19 Event Form - LTCF Modified 6768 4512 0 Form 0920-1317 VA COVID-19 Resident Event Form
Form and Instruction 0920-1317 Resident COVID-19 Event Form 22SEP2021
VA - Staff and Personnel COVID-19 Event Form - LTCF Modified 6768 2820 0 Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form
Form and Instruction 0920-1317 Staff and Personnel COVID-19 Event Form 22SEP2021
Ventilator Capacity & Supplies - Business and Financial Operations Occupations Unchanged 97240 8103 0 Form and Instruction CDC 57.147 Ventilator Capacity & Supplies
Ventilator Capacity & Supplies - LCTF Personnel Unchanged 604292 50358 0 Form and Instruction CDC 57.147 Ventilator Capacity & Supplies
Ventilator Capacity & Supplies - State and Local Health Dept Occupations Unchanged 97240 8103 0 Form and Instruction CDC 57.147 Ventilator Capacity & Supplies
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary New 655200 982800 0 Form and Instruction 0920-1317 / CDC Form 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary
Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities New 400400 500500 0 Form and Instruction 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 New 876928 1096160 0 Form and Instruction 0920-1317 / CDC Form 57.218 Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities
Total burden requested under this ICR: 7502054 4736898 0  
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