Monthly Reporting Plan form for Long-term Care Facilities

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CDC Form 57.141 Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction
Form CDC Form 57.141 Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction
CDC Form 57.141 Monthly Reporting Plan for LTCF 57.141_ReportPlan_LTCF_July2021.docx Form and Instruction
CDC Form 57.141 Monthly Reporting Plan for LTCF 57.141_ReportPlan_LTCF_July2021.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Monthly Reporting Plan form for Long-term Care Facilities	Agency IC Tracking Number:	0920-1317

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CDC Form 57.141	Monthly Reporting Plan for LTCF	57.141_ReportPlan_LTCF_July2021.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16,864	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	151,776	151,776
Annual IC Time Burden (Hours)	12,648	12,648
Annual IC Cost Burden (Dollars)	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.