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

OMB 0920-1317

Latest Forms, Documents, and Supporting Material

Document Name
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility-CSV Form and Instruction
Form 57.509 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV Form and Instruction
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV Form and Instruction
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_Manual Form and Instruction
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_CSV Form and Instruction
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component _Manual Form and Instruction
Form 57.220 57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_CSV Form and Instruction
Form 57.220 57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_Manual Form and Instruction
Form 57.155 57.155 Point of Care Testing Results - CSV Form and Instruction
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) Form and Instruction
Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv) Form and Instruction
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) Form and Instruction
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv) Form and Instruction
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual) Form and Instruction
Form 57.102 57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction
Form 57.102 57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction
Form 57.102 57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction
Form 57.155 57.155 Point of Care Testing Results - Manual Form and Instruction
NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs) Form and Instruction
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Form and Instruction
Form CDC Form 57.203 Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction
Form CDC Form 57.141 Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction
Form 57.509 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual Form and Instruction
Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) Form and Instruction
Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form - LTCF Form and Instruction
Form 0920-1317 VA - Resident COVID-19 Event Form - LTCF Form and Instruction
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility_Manual Form and Instruction
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Form and Instruction
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Form and Instruction
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel retrospective Form and Instruction
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations Form and Instruction
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations Form and Instruction
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel Form and Instruction
Form CDC 57.144 Long Term Care Facility Resident Impact and Facility Capacity Pathway Form and Instruction
Form 0920-1317 57.140 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction
D. Explanation for Program Changes or Adjustments.docx Supplementary Document
G2. Privacy Impact Assessment.pdf Supplementary Document
G1. Privacy Impact Assessment.pdf Supplementary Document
G. Privacy Impact Assessment.pdf Supplementary Document
E3. Human Subjects Determination.pdf Supplementary Document
B. FRN-60 day.pdf Supplementary Document
SSB 0920-1317 NHSN COVID-19_FINAL.docx Supporting Statement B
SSA 0920-1317 NHSN COVID-19_FINAL.docx Supporting Statement A
Change Memo 0920-1317 August 2024_FINAL_v2.docx Justification for No Material/Nonsubstantive Change
Change Memo 0920-1317.docx Justification for No Material/Nonsubstantive Change
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx Justification for No Material/Nonsubstantive Change
Change Memo for CDC NHSN COVID-19 OMB Package 0920-1317.docx Justification for No Material/Nonsubstantive Change
Resident Impact and Facility Capacity- csv temp..csv Supplementary Document
TOI-Facility Importing COVID-19 and Respiratory Infections using a .csv file_RIFC.docx Supplementary Document
Change Memo for NHSN September 2023_0920_1317.docx Justification for No Material/Nonsubstantive Change
Crosswalk_57.218.docx Supplementary Document
Crosswalk_57.144.docx Supplementary Document
Crosswalk-COVID-19 Hospital Data.docx Supplementary Document
Crosswalk 11.4 updated COVID JUNE_final.docx Supplementary Document
Change Memo for NHSN May 2023_0920_1317_final.docx Justification for No Material/Nonsubstantive Change
CDC Response to APIC Dec29 letter sk lw.docx Supplementary Document
5. NHSN - Report of End of Human Research Review 0.1253.docx Supplementary Document
6. IRB Protocol Closure.pdf Supplementary Document
3. Privacy Act Checklist 2022.docx Supplementary Document
1c. 42 USC 242m.PDF Supplementary Document
1b. 42 USC 242k.PDF Supplementary Document
1a. 42 USC 242b.PDF Supplementary Document
57.510 COVID–19 Module Dialysis Outpatient Facility-CSV Form and Instruction
57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV Form and Instruction
57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV Form and Instruction
57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_Manual Form and Instruction
57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_CSV Form and Instruction
57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component _Manual Form and Instruction
57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_CSV Form and Instruction
57.220 Weekly Person Level Respiratory Pathogen and Vaccination for Residents-LTCF Component_Manual Form and Instruction
57.155 Point of Care Testing Results - CSV Form and Instruction
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) Form and Instruction
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv) Form and Instruction
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) Form and Instruction
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv) Form and Instruction
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual) Form and Instruction
57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction
57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction
57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction
57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction
57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction
57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction
57.155 Point of Care Testing Results - Manual Form and Instruction
NHSN COVID-19 Hospital Module (Infusion Centers and Outpatient Clinics reporting Inventory & use of therapeutics (MABs) Form and Instruction
Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Form and Instruction
Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction
Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction
57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual Form and Instruction
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) Form and Instruction
VA - Staff and Personnel COVID-19 Event Form - LTCF Form and Instruction
VA - Resident COVID-19 Event Form - LTCF Form and Instruction
57.510 COVID–19 Module Dialysis Outpatient Facility_Manual Form and Instruction
Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Form and Instruction
Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Form and Instruction
Staff and Personnel Impact - LTCF Personnel retrospective Form and Instruction
Staff and Personnel Impact - State and Local Health Dept Occupations Form and Instruction
Staff and Personnel Impact - Business and Financial Operations Occupations Form and Instruction
Staff and Personnel Impact - LTCF Personnel Form and Instruction
Long Term Care Facility Resident Impact and Facility Capacity Pathway Form and Instruction
57.140 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction