Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Dialysis Component Modified 800800 333667 0 Form and Instruction n/a COVID–19 Module - Dialysis Outpatient Facility
Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Modified 69300 5775 0 Form and Instruction CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan
Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Modified 4728 394 0 Form and Instruction CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan
Monthly Reporting Plan form for Long-term Care Facilities Modified 151776 12648 0 Form and Instruction CDC Form 57.141 Monthly Reporting Plan for LTCF
NHSN COVID-19 Hospital Module (Hospitals) New 2190000 3285000 0 Form and Instruction n/a NHSN COVID-19 Hospital Module
NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs) New 20800 5200 0 Form and Instruction n/a NHSN COVID-19 Hospital Module Infusion Centers and Outpatient Clinics
NHSN and Secure Access Management Services (SAMS) enrollment Modified 11500 11500 0 Form and Instruction 0920-1317 NHSN Registration Form
Resident Impact and Facility Capacity - Business and Financial Operations Occupations Removed 0 0 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 / CDC 57.144 Resident Impact and Facility Capacity Form 23MAY2022
Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective Modified 935 623 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - LTCF Personnel retrospective Modified 5811 3874 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - LTCF Personnel, Business and Financial operations and State and Local Health Dept. Occupations Modified 858624 858624 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - State and Local Health Dept Occupations Removed 0 0 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 / CDC 57.144 Resident Impact and Facility Capacity Form 23MAY2022
Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective Modified 935 623 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Resident Therapeutics - Business and Financial Operations Occupations Modified 97240 16207 0 Form and Instruction 0920-1317 CDC 57.XXX Long Term Care Facility: Resident Therapeutics
Resident Therapeutics - LTCF Personnel Modified 604292 100715 0 Form and Instruction 0920-1317 CDC 57.XXX Long-Term Care Facility: Resident Therapeutics
Resident Therapeutics - State and Local Health Dept. Occupations Modified 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 Modified 97240 24310 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Modified 935 234 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel Modified 604292 151073 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel retrospective Modified 5811 1453 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations Modified 97240 24310 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Modified 935 234 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
VA - Resident COVID-19 Event Form - LTCF Modified 6768 3948 0 Form and Instruction 0920-1317 VA COVID-19 Resident Event Form
VA - Staff and Personnel COVID-19 Event Form - LTCF Modified 6768 2256 0 Form and Instruction 0920-1317 VA - Staff and Personnel COVID-19 Event Form
Ventilator Capacity & Supplies - Business and Financial Operations Occupations Removed 0 0 0 Form and Instruction CDC 57.147 Ventilator Capacity & Supplies
Ventilator Capacity & Supplies - LCTF Personnel Removed 0 0 0 Form and Instruction CDC 57.147 Ventilator Capacity & Supplies
Ventilator Capacity & Supplies - State and Local Health Dept Occupations Removed 0 0 0 Form and Instruction CDC 57.147 Ventilator Capacity & Supplies
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Modified 655200 982800 0 Form and Instruction CDC Form 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary
Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Modified 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 Modified 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: 7666498 7438335 0  
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