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

ICR 202305-0920-005

OMB: 0920-1317

Federal Form Document

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	Unchanged
NHSN COVID-19 Hospital Module (Hospitals) Form and Instruction	Unchanged
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Form and Instruction	Unchanged
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction	Unchanged
Form CDC Form 57.141 Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction	Unchanged
Form 0920-1317 / CDC Fo Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Form and Instruction	Unchanged
Form 0920-1317 / CDC Fo Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	Unchanged
Form CDC Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction	Unchanged
Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form - LTCF Form and Instruction	Unchanged
Form 0920-1317 VA - Resident COVID-19 Event Form - LTCF Form and Instruction	Unchanged
Form 0920-1317 CDC 57.X Resident Therapeutics - State and Local Health Dept. Occupations Form and Instruction	Removed
Form 0920-1317 CDC 57.X Resident Therapeutics - Business and Financial Operations Occupations Form and Instruction	Removed
Form 0920-1317 CDC 57.X Resident Therapeutics - LTCF Personnel Form and Instruction	Removed
Dialysis Component Form and Instruction	Unchanged
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 - 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	Unchanged
Crosswalk 11.4 updated COVID JUNE_final.docx Supplementary Document	2023-05-18
Change Memo for NHSN May 2023_0920_1317_final.docx Justification for No Material/Nonsubstantive Change	2023-05-18
CDC Response to APIC Dec29 letter sk lw.docx Supplementary Document	2023-03-06
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	Unchanged
257193	NHSN COVID-19 Hospital Module (Hospitals) Form and Instruction	Unchanged
249439	Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Form and Instruction	Unchanged
249438	Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction	Unchanged
249437	Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction	Unchanged
249436	Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Form and Instruction	Unchanged
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	Unchanged
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction	Unchanged
247669	VA - Staff and Personnel COVID-19 Event Form - LTCF Form and Instruction	Unchanged
247668	VA - Resident COVID-19 Event Form - LTCF Form and Instruction	Unchanged
245466	Resident Therapeutics - State and Local Health Dept. Occupations Form and Instruction	Removed
245464	Resident Therapeutics - Business and Financial Operations Occupations Form and Instruction	Removed
245463	Resident Therapeutics - LTCF Personnel Form and Instruction	Removed
243719	Dialysis Component Form and Instruction	Unchanged
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
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	Unchanged