[NCEZID] National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities

ICR 202211-0920-014

OMB: 0920-1317

Federal Form Document

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0920-1317 can be found here:

2025-09-30 - No material or nonsubstantive change to a currently approved collection
2025-03-28 - No material or nonsubstantive change to a currently approved collection

Forms and Documents

Document Name	Status
NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs) Form and Instruction	New
NHSN COVID-19 Hospital Module (Hospitals) Form and Instruction	New
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Form and Instruction	Modified
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction	Modified
Form CDC Form 57.141 Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction	Modified
Form 0920-1317 / CDC Fo Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Form and Instruction	Modified
Form 0920-1317 / CDC Fo Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	Modified
Form CDC Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction	Modified
Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form - LTCF Form and Instruction	Modified
Form 0920-1317 VA - Resident COVID-19 Event Form - LTCF Form and Instruction	Modified
Form 0920-1317 CDC 57.X Resident Therapeutics - State and Local Health Dept. Occupations Form and Instruction	Modified
Form 0920-1317 CDC 57.X Resident Therapeutics - Business and Financial Operations Occupations Form and Instruction	Modified
Form 0920-1317 CDC 57.X Resident Therapeutics - LTCF Personnel Form and Instruction	Modified
Dialysis Component Form and Instruction	Modified
Form CDC 57.147 Ventilator Capacity & Supplies - State and Local Health Dept Occupations Form and Instruction	Removed
Form CDC 57.147 Ventilator Capacity & Supplies - Business and Financial Operations Occupations Form and Instruction	Removed
Form CDC 57.147 Ventilator Capacity & Supplies - LCTF Personnel Form and Instruction	Removed
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Form and Instruction	Modified
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Form and Instruction	Modified
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel retrospective Form and Instruction	Modified
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations Form and Instruction	Modified
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations Form and Instruction	Modified
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel Form and Instruction	Modified
Form CDC 57.144 Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective Form and Instruction	Modified
Form CDC 57.144 Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective Form and Instruction	Modified
Form CDC 57.144 Resident Impact and Facility Capacity - LTCF Personnel retrospective Form and Instruction	Modified
Form CDC 57.144 Resident Impact and Facility Capacity - State and Local Health Dept Occupations Form and Instruction	Removed
Form CDC 57.144 Resident Impact and Facility Capacity - Business and Financial Operations Occupations Form and Instruction	Removed
Form CDC 57.144 Resident Impact and Facility Capacity - LTCF Personnel, Business and Financial operations and State and Local Health Dept. Occupations Form and Instruction	Modified
Form 0920-1317 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction	Modified
5. NHSN - Report of End of Human Research Review 0.1253.docx Supplementary Document	2022-11-28
6. IRB Protocol Closure.pdf Supplementary Document	2022-11-28
3. Privacy Act Checklist 2022.docx Supplementary Document	2022-11-28
2. Published 60-day FRN.pdf Supplementary Document	2022-11-28
1c. 42 USC 242m.PDF Supplementary Document	2022-11-28
1b. 42 USC 242k.PDF Supplementary Document	2022-11-28
1a. 42 USC 242b.PDF Supplementary Document	2022-11-28
SSB 0920-1317 NHSN COVID-19 Module.docx Supporting Statement B	2022-11-29
SSA 0920-1317 NHSN COVID-19 Module_final.docx Supporting Statement A	2022-11-30

IC Document Collections

IC ID	Document Title	Status
257194	NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs) Form and Instruction	New
257193	NHSN COVID-19 Hospital Module (Hospitals) Form and Instruction	New
249439	Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Form and Instruction	Modified
249438	Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction	Modified
249437	Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction	Modified
249436	Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Form and Instruction	Modified
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	Modified
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction	Modified
247669	VA - Staff and Personnel COVID-19 Event Form - LTCF Form and Instruction	Modified
247668	VA - Resident COVID-19 Event Form - LTCF Form and Instruction	Modified
245466	Resident Therapeutics - State and Local Health Dept. Occupations Form and Instruction	Modified
245464	Resident Therapeutics - Business and Financial Operations Occupations Form and Instruction	Modified
245463	Resident Therapeutics - LTCF Personnel Form and Instruction	Modified
243719	Dialysis Component Form and Instruction	Modified
243718	Ventilator Capacity & Supplies - State and Local Health Dept Occupations Form and Instruction	Removed
243717	Ventilator Capacity & Supplies - Business and Financial Operations Occupations Form and Instruction	Removed
243716	Ventilator Capacity & Supplies - LCTF Personnel Form and Instruction	Removed
243711	Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Form and Instruction	Modified
243710	Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Form and Instruction	Modified
243709	Staff and Personnel Impact - LTCF Personnel retrospective Form and Instruction	Modified
243708	Staff and Personnel Impact - State and Local Health Dept Occupations Form and Instruction	Modified
243707	Staff and Personnel Impact - Business and Financial Operations Occupations Form and Instruction	Modified
243706	Staff and Personnel Impact - LTCF Personnel Form and Instruction	Modified
243704	Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective Form and Instruction	Modified
243703	Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective Form and Instruction	Modified
243702	Resident Impact and Facility Capacity - LTCF Personnel retrospective Form and Instruction	Modified
243701	Resident Impact and Facility Capacity - State and Local Health Dept Occupations Form and Instruction	Removed
243700	Resident Impact and Facility Capacity - Business and Financial Operations Occupations Form and Instruction	Removed
243699	Resident Impact and Facility Capacity - LTCF Personnel, Business and Financial operations and State and Local Health Dept. Occupations Form and Instruction	Modified
243698	NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction	Modified

ICR Details