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

Forms and Documents

Document Name	Status
Form 0920-1317 / CDC Fo Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Form and Instruction	New
Form 0920-1317 / CDC Fo Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction	New
Form 0920-1317 / CDC Fo Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction	New
Form 0920-1317 / CDC Fo Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Form and Instruction	New
Form 0920-1317 / CDC Fo Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	New
Form 0920-1317 / CDC Fo Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction	New
Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form - LTCF Form	Modified
Form 0920-1317 VA - Resident COVID-19 Event Form - LTCF Form	Modified
Form 0920-1317 CDC 57.X Resident Therapeutics - State and Local Health Dept. Occupations Form and Instruction	Unchanged
Form 0920-1317 CDC 57.X Resident Therapeutics - Business and Financial Operations Occupations Form and Instruction	Unchanged
Form 0920-1317 CDC 57.X Resident Therapeutics - LTCF Personnel Form and Instruction	Modified
Form 0920-20LW Dialysis Component Form and Instruction	Modified
Form CDC 57.147 Ventilator Capacity & Supplies - State and Local Health Dept Occupations Form and Instruction	Unchanged
Form CDC 57.147 Ventilator Capacity & Supplies - Business and Financial Operations Occupations Form and Instruction	Unchanged
Form CDC 57.147 Ventilator Capacity & Supplies - LCTF Personnel Form and Instruction	Unchanged
Form CDC 57.146 Supplies & Personal Protective Equipment - State and Local Health Dept Occupations Form and Instruction	Unchanged
Form CDC 57.146 Supplies & Personal Protective Equipment - Business and Financial Operations Occupations Form and Instruction	Unchanged
Form CDC 57.146 Supplies & Personal Protective Equipment - LTCF Personnel Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel retrospective Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - State and Local Health Dept Occupations Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - Business and Financial Operations Occupations Form and Instruction	Unchanged
Form CDC 57.145 Staff and Personnel Impact - LTCF Personnel Form and Instruction	Unchanged
Form CDC 57.144 Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective Form and Instruction	Unchanged
Form CDC 57.144 Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective Form and Instruction	Unchanged
Form CDC 57.144 Resident Impact and Facility Capacity - LTCF Personnel retrospective Form and Instruction	Unchanged
Form CDC 57.144 Resident Impact and Facility Capacity - State and Local Health Dept Occupations Form and Instruction	Unchanged
Form CDC 57.144 Resident Impact and Facility Capacity - Business and Financial Operations Occupations Form and Instruction	Unchanged
Form CDC 57.144 Resident Impact and Facility Capacity - LTCF Personnel Form and Instruction	Modified
Form 0920-20LW NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction	Unchanged
Change Memo 0920-1317 NHSN COVID SEP22_final.docx Justification for No Material/Nonsubstantive Change	2021-09-22
Change Memo for NHSN VHA_tb_lw.tbg3 final.docx Justification for No Material/Nonsubstantive Change	2021-05-28
0920-1317 Change Memo - NHSN LTCF PPE_DIALYSIS_TBG.docx Justification for No Material/Nonsubstantive Change	2021-02-25
NHSN COVID Module Non-sub change request 012621.docx Justification for No Material/Nonsubstantive Change	2021-01-28
Att6_NHSN Report of End of Human Research Review.docx Supplementary Document	2020-09-21
Att5_Closure of CDC Protocol 4062.docx Supplementary Document	2020-09-21
Att4_How to Enter and Access COVID Summary Data.docx Supplementary Document	2020-09-21
Att3_PIA.pdf Supplementary Document	2020-09-21
Att2_60 Day FRN.pdf Supplementary Document	2020-09-21
Att1c_42 USC 242m.pdf Supplementary Document	2020-09-21
Att1b_42 USC 242k.pdf Supplementary Document	2020-09-21
Att1a_42 USC 242b.pdf Supplementary Document	2020-09-21
Supporting Statement B NHSN COVID-19_clean.09.01.20 .docx Supporting Statement B	2020-09-21
NHSN COVID SSA_15JAN2021.docx Supporting Statement A	2021-01-15

IC Document Collections

IC ID	Document Title	Status
249439	Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities Form and Instruction	New
249438	Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities Form and Instruction	New
249437	Monthly Reporting Plan form for Long-term Care Facilities Form and Instruction	New
249436	Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities Form and Instruction	New
249435	Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities Form and Instruction	New
249434	Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction	New
247669	VA - Staff and Personnel COVID-19 Event Form - LTCF Form	Modified
247668	VA - Resident COVID-19 Event Form - LTCF Form	Modified
245466	Resident Therapeutics - State and Local Health Dept. Occupations Form and Instruction	Unchanged
245464	Resident Therapeutics - Business and Financial Operations Occupations Form and Instruction	Unchanged
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	Unchanged
243717	Ventilator Capacity & Supplies - Business and Financial Operations Occupations Form and Instruction	Unchanged
243716	Ventilator Capacity & Supplies - LCTF Personnel Form and Instruction	Unchanged
243714	Supplies & Personal Protective Equipment - State and Local Health Dept Occupations Form and Instruction	Unchanged
243713	Supplies & Personal Protective Equipment - Business and Financial Operations Occupations Form and Instruction	Unchanged
243712	Supplies & Personal Protective Equipment - LTCF Personnel Form and Instruction	Unchanged
243711	Staff and Personnel Impact - State and Local Health Dept Occupations retrospective Form and Instruction	Unchanged
243710	Staff and Personnel Impact - Business and Financial Operations Occupations retrospective Form and Instruction	Unchanged
243709	Staff and Personnel Impact - LTCF Personnel retrospective Form and Instruction	Unchanged
243708	Staff and Personnel Impact - State and Local Health Dept Occupations Form and Instruction	Unchanged
243707	Staff and Personnel Impact - Business and Financial Operations Occupations Form and Instruction	Unchanged
243706	Staff and Personnel Impact - LTCF Personnel Form and Instruction	Unchanged
243704	Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective Form and Instruction	Unchanged
243703	Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective Form and Instruction	Unchanged
243702	Resident Impact and Facility Capacity - LTCF Personnel retrospective Form and Instruction	Unchanged
243701	Resident Impact and Facility Capacity - State and Local Health Dept Occupations Form and Instruction	Unchanged
243700	Resident Impact and Facility Capacity - Business and Financial Operations Occupations Form and Instruction	Unchanged
243699	Resident Impact and Facility Capacity - LTCF Personnel Form and Instruction	Modified
243698	NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-1317	ICR Reference No: 202109-0920-006
Status: Received in OIRA	Previous ICR Reference No: 202105-0920-014
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1317-21IH
Title: National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/22/2021

	Requested	Previously Approved
Expiration Date	01/31/2024	01/31/2024
Responses	7,502,054	5,052,366
Time Burden (Hours)	4,736,898	1,732,245
Cost Burden (Dollars)	0	0

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Abstract: The goal of this information collection is to 1) capture the daily, aggregate impact of COVID-19 on healthcare facilities, and 2) monitor medical capacity to respond at local, state, and national levels. This information will be used to inform the overall real-time COVID-19 response efforts and possible resource allocation, and enable state and local health departments to gain immediate access to the COVID-19 data for healthcare facilities within their jurisdiction. This Non-Substantive Change Request is submitted to improve the usefulness and quality of data that is gathered regarding residents with newly positive SARS-CoV-2 viral test results and their vaccination status. This will also likely aid in improving the quality of data which can be used regarding break-through cases.

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Authorizing Statute(s): US Code: 42 USC 242b, k, m Name of Law: The Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 21443	04/17/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 59313	09/21/2020
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 31

IC Title	Form No.	Form Name
Dialysis Component	0920-20LW, 0920-1317, 0920-1317, 0920-1317 / Form 57.510	Dialysis Component ,   COVID-19 Module Dialysis Outpatient Facility ,   COVID-19 Module Dialysis Outpatient Facility Form 27MAY2021 ,   COVID–19 Module - Dialysis Outpatient Facility
Healthcare Personnel Safety Monthly Reporting Plan - completed by Dialysis Facilities	0920-1317 / CDC Form 57.203	Healthcare Personnel Safety Monthly Reporting Plan
Healthcare Personnel Safety Monthly Reporting Plan - completed by Inpatient Psychiatric Facilities	0920-1317 / CDC Form 57.203	Healthcare Personnel Safety Monthly Reporting Plan
Monthly Reporting Plan form for Long-term Care Facilities	0920-1317 / CDC Form 57.141	Monthly Reporting Plan for LTCF
NHSN and Secure Access Management Services (SAMS) enrollment	0920-20LW	NHSN Registration Form
Resident Impact and Facility Capacity - Business and Financial Operations Occupations	CDC 57.144, 0920-1317 CDC 57.144	Resident Impact and Facility Capacity ,   Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - Business and Financial Operations Occupations retrospective	CDC 57.144	Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - LTCF Personnel	0920-1317 Form 57.144, 0920-1317 CDC 57.144, CDC 57.144	Resident Impact and Facility Capacity ,   Resident Impact and Facility Capacity ,   Resident Impact and Facility Capacity Form 21SEP2021
Resident Impact and Facility Capacity - LTCF Personnel retrospective	CDC 57.144	Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - State and Local Health Dept Occupations	CDC 57.144, 0920-1317 CDC 57.144	Resident Impact and Facility Capacity ,   Resident Impact and Facility Capacity
Resident Impact and Facility Capacity - State and Local Health Dept Occupations retrospective	CDC 57.144	Resident Impact and Facility Capacity
Resident Therapeutics - Business and Financial Operations Occupations	0920-1317 CDC 57.XXX	Long Term Care Facility: Resident Therapeutics
Resident Therapeutics - LTCF Personnel	0920-1317 CDC 57.XXX	Long-Term Care Facility: Resident Therapeutics
Resident Therapeutics - State and Local Health Dept. Occupations	0920-1317 CDC 57.XXX	Long Term Care Facility: Resident Therapeutics
Staff and Personnel Impact - Business and Financial Operations Occupations	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - Business and Financial Operations Occupations retrospective	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - LTCF Personnel retrospective	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations	CDC 57.145	Staff and Personnel Impact
Staff and Personnel Impact - State and Local Health Dept Occupations retrospective	CDC 57.145	Staff and Personnel Impact
Supplies & Personal Protective Equipment - Business and Financial Operations Occupations	CDC 57.146, CDC 57.146	Supplies & Personal Protective Equipment ,   COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
Supplies & Personal Protective Equipment - LTCF Personnel	CDC 57.146, CDC 57.146	Supplies & Personal Protective Equipment ,   COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
Supplies & Personal Protective Equipment - State and Local Health Dept Occupations	CDC 57.146, CDC 57.146	Supplies & Personal Protective Equipment ,   COVID-19 Module - LTCF: Supplies and Personal Protective Equipment
VA - Resident COVID-19 Event Form - LTCF	0920-1317, 0920-1317	VA COVID-19 Resident Event Form ,   Resident COVID-19 Event Form 22SEP2021
VA - Staff and Personnel COVID-19 Event Form - LTCF	0920-1317, 0920-1317	VA - Staff and Personnel COVID-19 Event Form ,   Staff and Personnel COVID-19 Event Form 22SEP2021
Ventilator Capacity & Supplies - Business and Financial Operations Occupations	CDC 57.147	Ventilator Capacity & Supplies
Ventilator Capacity & Supplies - LCTF Personnel	CDC 57.147	Ventilator Capacity & Supplies
Ventilator Capacity & Supplies - State and Local Health Dept Occupations	CDC 57.147	Ventilator Capacity & Supplies
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary	0920-1317 / CDC Form 57.219	Healthcare Personnel COVID-19 Vaccination Cumulative Summary
Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities	0920-1317 / CDC Form 57.509	Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities	0920-1317 / CDC Form 57.218	Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	7,502,054	5,052,366	0	2,449,688	0	0
Annual Time Burden (Hours)	4,736,898	1,732,245	0	3,004,653	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden change due to modifications made to the following 0920-1317 Forms: 1. Dialysis COVID-19 form (57.510) 2. LTCF Veterans Affairs Staff and Personnel COVID-19 Event form (57.160) 3. LTCF Veterans Affairs Resident COVID-19 Event form (57.159) 4. LTCF Point of Care Testing Results Tool (57.155) 5. LTCF Resident Impact and Facility Capacity form (57.144) 6. LTCF healthcare associated infections event form (57.142) 7. Weekly COVID-19 Vaccination Data Collection Forms & Monthly Reporting Plans: 57.203, 57.141, 57.509, 57.219, 57.218

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/22/2021

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