Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
COVID-19 Hospital Data Form (Psychiatric and Rehabilitation Facilities) New 870 1305 0 Form and Instruction 0920-1317 COVID-19 Hospital Data Form
Dialysis Component Unchanged 800800 333667 0 Form and Instruction n/a COVID–19 Module - Dialysis Outpatient Facility
Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Unchanged 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 Unchanged 4728 394 0 Form and Instruction CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan
Long Term Care Facility Resident Impact and Facility Capacity Pathway Modified 858000 357500 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Form and Instruction 57.144 COVID-19 and Respiratory Infections Module Long Term Care Facility Resident Impact and Facility Capacity Pathway Form (57.144) 07SEP2023
Monthly Reporting Plan form for Long-term Care Facilities Unchanged 151776 12648 0 Form and Instruction CDC Form 57.141 Monthly Reporting Plan for LTCF
NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs) Unchanged 20800 5200 0 Form and Instruction n/a NHSN COVID-19 Hospital Module Infusion Centers and Outpatient Clinics
NHSN COVID-19 Hospital Module - Hospitals (excluding Psychiatric and Rehabilitation Facilities) Modified 1898000 2847000 0 Form and Instruction n/a NHSN COVID-19 Hospital Module
Form and Instruction 0920-1317 COVID-19 Hospital Data Form
NHSN and Secure Access Management Services (SAMS) enrollment Unchanged 11500 11500 0 Form and Instruction 0920-1317 NHSN Registration Form
Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective Removed 0 0 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 Removed 0 0 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective Removed 0 0 0 Form and Instruction CDC 57.144 Resident Impact and Facility Capacity
Staff and Personnel Impact - Business and Financial Operations Occupations Unchanged 97240 8103 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Unchanged 935 78 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel Unchanged 604292 50358 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel retrospective Unchanged 5811 484 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations Unchanged 97240 8103 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Unchanged 935 78 0 Form and Instruction CDC 57.145 Staff and Personnel Impact
VA - Resident COVID-19 Event Form - LTCF Unchanged 6768 3948 0 Form and Instruction 0920-1317 VA COVID-19 Resident Event Form
VA - Staff and Personnel COVID-19 Event Form - LTCF Unchanged 6768 2256 0 Form and Instruction 0920-1317 VA - Staff and Personnel COVID-19 Event Form
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Unchanged 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 Unchanged 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 828100 483058 0 Form and Instruction 0920-1317 / CDC Form 57.218 Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities
Form and Instruction 57.218 Weekly Vaccination Cumulative Summary for Residents of Long-Term Care Facilities (57.218)
Total burden requested under this ICR: 6519463 5614755 0  
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