Information Collection

COVID-19 Patient Impact Module Form - Microbiologist

IC 240833 under ICR 202005-0920-008 · OMB 0920-1290.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1290 can be found here:

Documents and Forms

Document Name Document Type
COVID-19 Patient Impact Module Form - Microbiologist Form
Att4b_Instructions for COVID-19 Patient Impact Module Form_clean.docx Instruction
2. TOI_57.130_ v3_COVID19 patient impact and capacity FINAL.docx Instruction
COVID-19 Patient Impact Module Form Att4a_COVID-19 Patient Impact Module Form_clean.docx Form
0920-1290 COVID-19 Patient Impact Module Form - 14MAY2020 1. 57.130_v3_COVID-19_PIMHC_BLANK_FINAL.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	COVID-19 Patient Impact Module Form - Microbiologist	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NA	COVID-19 Patient Impact Module Form	Att4a_COVID-19 Patient Impact Module Form_clean.docx	NA	Yes	Yes	Fillable Fileable
Instruction			Att4b_Instructions for COVID-19 Patient Impact Module Form_clean.docx		Yes	Yes	Fillable Fileable
Form	0920-1290	COVID-19 Patient Impact Module Form - 14MAY2020	1. 57.130_v3_COVID-19_PIMHC_BLANK_FINAL.docx	NA	Yes	Yes	Fillable Fileable
Instruction			2. TOI_57.130_ v3_COVID19 patient impact and capacity FINAL.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: 2,079	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	374,220	0	374,220
Annual IC Time Burden (Hours)	218,295	62,370	155,925
Annual IC Cost Burden (Dollars)	0	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.