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

ICR 202502-0920-015

OMB: 0920-1317

Federal Form Document

Forms and Documents

Document Name	Status
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility-CSV Form and Instruction	Unchanged
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility-CSV Form and Instruction	Unchanged
Form 57.509 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV Form and Instruction	Unchanged
Form 57.509 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV Form and Instruction	Unchanged
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV Form and Instruction	Removed
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV Form and Instruction	Removed
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_Manual Form and Instruction	Removed
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_Manual Form and Instruction	Removed
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_CSV Form and Instruction	Removed
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_CSV Form and Instruction	Removed
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component _Manual Form and Instruction	Removed
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component _Manual Form and Instruction	Removed
Form 57.220 57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_CSV Form and Instruction	Removed
Form 57.220 57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_CSV Form and Instruction	Removed
Form 57.220 57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_Manual Form and Instruction	Removed
Form 57.220 57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_Manual Form and Instruction	Removed
Form 57.155 57.155 Point of Care Testing Results - CSV Form and Instruction	Modified
Form 57.155 57.155 Point of Care Testing Results - CSV Form and Instruction	Modified
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) Form and Instruction	Unchanged
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) Form and Instruction	Unchanged
Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction	Unchanged
Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction	Unchanged
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv) Form and Instruction	Modified
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv) Form and Instruction	Modified
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) Form and Instruction	Modified
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) Form and Instruction	Modified
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv) Form and Instruction	Modified
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv) Form and Instruction	Modified
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual) Form and Instruction	Modified
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual) Form and Instruction	Modified
Form 57.102 57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction	Unchanged
Form 57.102 57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction	Unchanged
Form 57.102 57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction	Unchanged
Form 57.102 57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction	Unchanged
Form 57.102 57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction	Unchanged
Form 57.102 57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction	Unchanged
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction	Unchanged
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction	Unchanged
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction	Unchanged
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction	Unchanged
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction	Unchanged
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction	Unchanged
Form 57.155 57.155 Point of Care Testing Results - Manual Form and Instruction	Modified
Form 57.155 57.155 Point of Care Testing Results - Manual Form and Instruction	Modified
Form 57.509 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual Form and Instruction	Unchanged
Form 57.509 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual Form and Instruction	Unchanged
Form Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction	Unchanged
Form Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction	Unchanged
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) Form and Instruction	Unchanged
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) Form and Instruction	Unchanged
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility_Manual Form and Instruction	Unchanged
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility_Manual Form and Instruction	Unchanged
Form 0920-1317 57.140 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction	Unchanged
Form 0920-1317 57.140 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction	Unchanged
Change Request Memo - EO14168.docx Justification for No Material/Nonsubstantive Change	2025-03-04
Change Request Memo - EO14168.docx Justification for No Material/Nonsubstantive Change	2025-03-04
Change Memo 0920-1317 December 2024.docx Justification for No Material/Nonsubstantive Change	2025-01-09
Change Memo 0920-1317 December 2024.docx Justification for No Material/Nonsubstantive Change	2025-01-09
D. Explanation for Program Changes or Adjustments.docx Supplementary Document	2024-10-29
D. Explanation for Program Changes or Adjustments.docx Supplementary Document	2024-10-29
G2. Privacy Impact Assessment.pdf Supplementary Document	2024-10-29
G2. Privacy Impact Assessment.pdf Supplementary Document	2024-10-29
G1. Privacy Impact Assessment.pdf Supplementary Document	2024-10-29
G1. Privacy Impact Assessment.pdf Supplementary Document	2024-10-29
G. Privacy Impact Assessment.pdf Supplementary Document	2024-10-29
G. Privacy Impact Assessment.pdf Supplementary Document	2024-10-29
E3. Human Subjects Determination.pdf Supplementary Document	2024-10-29
E3. Human Subjects Determination.pdf Supplementary Document	2024-10-29
B. FRN-60 day.pdf Supplementary Document	2024-10-29
B. FRN-60 day.pdf Supplementary Document	2024-10-29
SSB 0920-1317 NHSN COVID-19_FINAL.docx Supporting Statement B	2024-10-29
SSB 0920-1317 NHSN COVID-19_FINAL.docx Supporting Statement B	2024-10-29
SSA 0920-1317 NHSN COVID 08JAN2025.docx Supporting Statement A	2025-03-04
SSA 0920-1317 NHSN COVID 08JAN2025.docx Supporting Statement A	2025-03-04
Change Memo 0920-1317 August 2024_FINAL_v2.docx Justification for No Material/Nonsubstantive Change	2024-08-22
Change Memo 0920-1317 August 2024_FINAL_v2.docx Justification for No Material/Nonsubstantive Change	2024-08-22
Change Memo 0920-1317.docx Justification for No Material/Nonsubstantive Change	2024-08-06
Change Memo 0920-1317.docx Justification for No Material/Nonsubstantive Change	2024-08-06
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx Justification for No Material/Nonsubstantive Change	2024-04-26
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx Justification for No Material/Nonsubstantive Change	2024-04-26
Change Memo for CDC NHSN COVID-19 OMB Package 0920-1317.docx Justification for No Material/Nonsubstantive Change	2024-03-14
Change Memo for CDC NHSN COVID-19 OMB Package 0920-1317.docx Justification for No Material/Nonsubstantive Change	2024-03-14
Resident Impact and Facility Capacity- csv temp..csv Supplementary Document	2023-09-07
Resident Impact and Facility Capacity- csv temp..csv Supplementary Document	2023-09-07
TOI-Facility Importing COVID-19 and Respiratory Infections using a .csv file_RIFC.docx Supplementary Document	2023-09-07
TOI-Facility Importing COVID-19 and Respiratory Infections using a .csv file_RIFC.docx Supplementary Document	2023-09-07
Change Memo for NHSN September 2023_0920_1317.docx Justification for No Material/Nonsubstantive Change	2023-09-07
Change Memo for NHSN September 2023_0920_1317.docx Justification for No Material/Nonsubstantive Change	2023-09-07
Crosswalk_57.218.docx Supplementary Document	2023-09-07
Crosswalk_57.218.docx Supplementary Document	2023-09-07
Crosswalk_57.144.docx Supplementary Document	2023-09-07
Crosswalk_57.144.docx Supplementary Document	2023-09-07
Crosswalk-COVID-19 Hospital Data.docx Supplementary Document	2023-09-07
Crosswalk-COVID-19 Hospital Data.docx Supplementary Document	2023-09-07
Crosswalk 11.4 updated COVID JUNE_final.docx Supplementary Document	2023-05-18
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
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
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
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
6. IRB Protocol Closure.pdf Supplementary Document	2022-11-28
3. Privacy Act Checklist 2022.docx Supplementary Document	2022-11-28
3. Privacy Act Checklist 2022.docx Supplementary Document	2022-11-28
1c. 42 USC 242m.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
1b. 42 USC 242k.PDF Supplementary Document	2022-11-28
1a. 42 USC 242b.PDF Supplementary Document	2022-11-28
1a. 42 USC 242b.PDF Supplementary Document	2022-11-28

IC Document Collections

IC ID	Document Title	Status
271955	57.510 COVID–19 Module Dialysis Outpatient Facility-CSV Form and Instruction	Unchanged
271955	57.510 COVID–19 Module Dialysis Outpatient Facility-CSV Form and Instruction	Unchanged
271950	57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV Form and Instruction	Unchanged
271950	57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV Form and Instruction	Unchanged
271948	57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV Form and Instruction	Removed
271948	57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV Form and Instruction	Removed
271947	57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_Manual Form and Instruction	Removed
271947	57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_Manual Form and Instruction	Removed
271946	57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_CSV Form and Instruction	Removed
271946	57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_CSV Form and Instruction	Removed
271945	57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component _Manual Form and Instruction	Removed
271945	57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component _Manual Form and Instruction	Removed
271943	57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_CSV Form and Instruction	Removed
271943	57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_CSV Form and Instruction	Removed
271941	57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_Manual Form and Instruction	Removed
271941	57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_Manual Form and Instruction	Removed
271935	57.155 Point of Care Testing Results - CSV Form and Instruction	Modified
271935	57.155 Point of Care Testing Results - CSV Form and Instruction	Modified
270333	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) Form and Instruction	Unchanged
270333	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) Form and Instruction	Unchanged
270316	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction	Unchanged
270316	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction	Unchanged
270313	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv) Form and Instruction	Modified
270313	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv) Form and Instruction	Modified
270312	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) Form and Instruction	Modified
270312	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) Form and Instruction	Modified
270310	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv) Form and Instruction	Modified
270310	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv) Form and Instruction	Modified
270309	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual) Form and Instruction	Modified
270309	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual) Form and Instruction	Modified
269868	57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction	Unchanged
269868	57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction	Unchanged
269867	57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction	Unchanged
269867	57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction	Unchanged
269866	57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction	Unchanged
269866	57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction	Unchanged
269865	57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction	Unchanged
269865	57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction	Unchanged
269864	57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction	Unchanged
269864	57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction	Unchanged
269863	57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction	Unchanged
269863	57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction	Unchanged
266012	57.155 Point of Care Testing Results - Manual Form and Instruction	Modified
266012	57.155 Point of Care Testing Results - Manual Form and Instruction	Modified
249436	57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual Form and Instruction	Unchanged
249436	57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual Form and Instruction	Unchanged
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction	Unchanged
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction	Unchanged
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) Form and Instruction	Unchanged
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) Form and Instruction	Unchanged
243719	57.510 COVID–19 Module Dialysis Outpatient Facility_Manual Form and Instruction	Unchanged
243719	57.510 COVID–19 Module Dialysis Outpatient Facility_Manual Form and Instruction	Unchanged
243698	57.140 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction	Unchanged
243698	57.140 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction	Unchanged