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COVID-19 Patient Impact Module Form - Microbiologist
National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities
OMB: 0920-1290
IC ID: 240833
OMB.report
HHS/CDC
OMB 0920-1290
ICR 202008-0920-012
IC 240833
( )
Documents and Forms
Document Name
Document Type
COVID-19 Patient Impact Module Form - Microbiologist
Form
Att4b_Instructions for COVID-19 Patient Impact Module Form_clean.docx
Instruction
2. TOI_57.130_ v3_COVID19 patient impact and capacity FINAL.docx
Instruction
TOI_57.130_ v4_COVID19 patient impact and capacity CLEAN.docx
Instruction
COVID-19 Patient Impact Module Form
Att4a_COVID-19 Patient Impact Module Form_clean.docx
Form
0920-1290 COVID-19 Patient Impact Module Form - 14MAY2020
1. 57.130_v3_COVID-19_PIMHC_BLANK_FINAL.docx
Form
00920-1290 COVID-19 Patient Impact Module Form 29MAY2020
57.130_v4_COVID-19_PIMHC_BLANK_CLEAN.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
COVID-19 Patient Impact Module Form - Microbiologist
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
NA
COVID-19 Patient Impact Module Form
Att4a_COVID-19 Patient Impact Module Form_clean.docx
NA
Yes
Yes
Fillable Fileable
Instruction
Att4b_Instructions for COVID-19 Patient Impact Module Form_clean.docx
Yes
Yes
Fillable Fileable
Form
0920-1290
COVID-19 Patient Impact Module Form - 14MAY2020
1. 57.130_v3_COVID-19_PIMHC_BLANK_FINAL.docx
NA
Yes
Yes
Fillable Fileable
Instruction
2. TOI_57.130_ v3_COVID19 patient impact and capacity FINAL.docx
NA
Yes
Yes
Fillable Fileable
Form
00920-1290
COVID-19 Patient Impact Module Form 29MAY2020
57.130_v4_COVID-19_PIMHC_BLANK_CLEAN.docx
NA
Yes
Yes
Fillable Fileable
Instruction
TOI_57.130_ v4_COVID19 patient impact and capacity CLEAN.docx
NA
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
2,079
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
374,220
0
0
0
0
374,220
Annual IC Time Burden (Hours)
249,480
0
0
0
0
249,480
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.