OMB control number

Emergency Extension - National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities

OMB 0920-1306 · HHS/CDC.

OMB 0920-1306

Latest Forms, Documents, and Supporting Material

Document Name
Dialysis Facility Infection Preventionists - NHSN New Facility Enrollment Form
Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form Form
Form 57.145 State and Local Health Department occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form
Form 57.145 Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form and Instruction
Form 57.145 LTCF - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form
Form 57.145 State and Local Health Department occupations -Staff and Personnel Impact form (57.145) Form
Form 57.145 Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) Form
Form 57.145 LTCF - Staff and Personnel Impact form (57.145) Form
Form 57.144 State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Datat Entry Form
Form 57.144 Business and Financial Operations occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry Form
Form 57.144 LTCF Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry Form
Form 57.144 State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) Form
Form 57.144 Business and Financial Operations Occupations - Resident Impact and Facility Capacity form (57.144) Form
Form 57.144 LTCF Personnel - Resident Impact and Facility Capacity form (57.144) Form
Form 57.155 NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel Form and Instruction
0920-1306 Change Memo - NHSN COVID-19 LTCF_11.10.20.docx Justification for No Material/Nonsubstantive Change
0920-1290 Change Memo - NHSN COVID-19 LTCF_10 15 20.docx Justification for No Material/Nonsubstantive Change
Revised SSB 15OCT2020.docx Supporting Statement B
Revised SSA 15OCT2020.docx Supporting Statement A
Revised Emergency Request Memo 15OCT2020.docx Supplementary Document
Dialysis Facility Infection Preventionists - NHSN New Facility Enrollment Form
Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form Form
State and Local Health Department occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form
Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form and Instruction
LTCF - Staff and Personnel Impact form (57.145) - Retrospective Data Entry Form
State and Local Health Department occupations -Staff and Personnel Impact form (57.145) Form
Business and Financial Operations occupations - Staff and Personnel Impact form (57.145) Form
LTCF - Staff and Personnel Impact form (57.145) Form
State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Datat Entry Form
Business and Financial Operations occupations - Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry Form
LTCF Resident Impact and Facility Capacity form (57.144) - Retrospective Data Entry Form
State and Local Health Department occupations - Resident Impact and Facility Capacity form (57.144) Form
Business and Financial Operations Occupations - Resident Impact and Facility Capacity form (57.144) Form
LTCF Personnel - Resident Impact and Facility Capacity form (57.144) Form
NHSN COVID-19 Long Term Care Facility (LTCF) Module - LTCF Personnel Form and Instruction

All Historical Document Collections

202011-0920-005 Approved with change	No material or nonsubstantive change to a currently approved collection	2020-11-11
202010-0920-008 Approved with change	New collection (Request for a new OMB Control Number)	2020-10-15