OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202509-0920-004 · OMB 0920-1317 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility-.csv Form and Instruction Unchanged Repair queued
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility-CSV Form and Instruction Unchanged Repair queued
Form 57.509 57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_CSV Form and Instruction Unchanged Available
Form 57.509 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV Form and Instruction Unchanged Repair queued
Form 57.155 Point of Care Testing Results Form and Instruction Unchanged Repair queued
Form 57.155 57.155 Point of Care Testing Results - CSV Form and Instruction Unchanged Repair queued
Form 57.219 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary_25SEP2025 Form and Instruction Modified Available
Form 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction Modified Available
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) Form and Instruction Modified Repair queued
Form 57.218 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025 Form and Instruction Modified Available
Form 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (.csv) Form and Instruction Modified Available
Form 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities Form and Instruction Modified Available
Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction Modified Repair queued
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel 29SEP2025 Form and Instruction Modified Available
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel Form and Instruction Modified Available
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv) Form and Instruction Modified Missing upstream
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel_29SEP2025 Form and Instruction Modified Repair queued
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel Form and Instruction Modified Available
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) Form and Instruction Modified Repair queued
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form 57.216_rev 29SEP2025 Form and Instruction Modified Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form and Instruction Modified Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv) Form and Instruction Modified Repair queued
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form 57.216_rev 29SEP2025 Form and Instruction Modified Available
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form and Instruction Modified Repair queued
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual) Form and Instruction Modified Repair queued
Form 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024 Form and Instruction Unchanged Available
Form 57.102 57.102 - Hospital Respiratory Data Fomr (Daily - API) Form and Instruction Unchanged Repair queued
Form 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024 Form and Instruction Unchanged Repair queued
Form 57.102 57.102 Hospital Respiratory Data Form (Daily - .csv import) Form and Instruction Unchanged Repair queued
Form 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024 Form and Instruction Unchanged Repair queued
Form 57.102 57.102 - Hospital Respiratory Data Form (Daily - user entry) Form and Instruction Unchanged Repair queued
Form 0920-1317 Hospital Respiratory Data Weekly Reporting Form Form and Instruction Unchanged Available
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - API) Form and Instruction Unchanged Repair queued
Form 0920-1317 Hospital Respiratory Data Weekly Reporting Form Form and Instruction Unchanged Available
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - .csv import) Form and Instruction Unchanged Repair queued
Form 0920-1317 Hospital Respiratory Data Weekly Reporting Form Form and Instruction Unchanged Available
Form 0920-1317 57.101 Hospital Respiratory Data Form (Weekly - User Entry) Form and Instruction Unchanged Repair queued
Form 57.155 Point of Care Testing Results Form and Instruction Unchanged Available
Form 57.155 57.155 Point of Care Testing Results - Manual Form and Instruction Unchanged Repair queued
Form 57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_Manual Form and Instruction Unchanged Available
Form 57.509 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual Form and Instruction Unchanged Repair queued
Form 57.218 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025 Form and Instruction Modified Repair queued
Form 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (manual) Form and Instruction Modified Available
Form Form 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities (manual) Form and Instruction Modified Available
Form Form 57.218 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction Modified Missing upstream
Form 57.219 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction Modified Available
Form 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary Form and Instruction Modified Available
Form 57.219 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) Form and Instruction Modified Repair queued
Form 57.510 COVID–19 Module - Dialysis Outpatient Facility Form and Instruction Unchanged Available
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility_Manual Form and Instruction Unchanged Repair queued
Form 0920-1317 NHSN Registration Form Form and Instruction Unchanged Repair queued
Form 0920-1317 57.140 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction Unchanged Repair queued
Change Memo 0920-1317 September 2025 FINAL_30SEP2025.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-09-30 Repair queued
Change Memo 0920-1317 September 2025 FINAL_30SEP2025.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-09-30 Missing upstream
Change Request Memo - EO14168.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-03-04 Available
Change Request Memo - EO14168.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-03-04 Repair queued
Change Memo 0920-1317 December 2024.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-01-09 Repair queued
Change Memo 0920-1317 December 2024.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-01-09 Missing upstream
D. Explanation for Program Changes or Adjustments.docx Supplementary Document Uploaded 2024-10-29 Repair queued
D. Explanation for Program Changes or Adjustments.docx Supplementary Document Uploaded 2024-10-29 Repair queued
G2. Privacy Impact Assessment.pdf Supplementary Document Uploaded 2024-10-29 Repair queued
G2. Privacy Impact Assessment.pdf Supplementary Document Uploaded 2024-10-29 Repair queued
G1. Privacy Impact Assessment.pdf Supplementary Document Uploaded 2024-10-29 Available
G1. Privacy Impact Assessment.pdf Supplementary Document Uploaded 2024-10-29 Repair queued
G. Privacy Impact Assessment.pdf Supplementary Document Uploaded 2024-10-29 Available
G. Privacy Impact Assessment.pdf Supplementary Document Uploaded 2024-10-29 Missing upstream
E3. Human Subjects Determination.pdf Supplementary Document Uploaded 2024-10-29 Available
E3. Human Subjects Determination.pdf Supplementary Document Uploaded 2024-10-29 Repair queued
B. FRN-60 day.pdf Supplementary Document Uploaded 2024-10-29 Repair queued
B. FRN-60 day.pdf Supplementary Document Uploaded 2024-10-29 Repair queued
SSB 0920-1317 NHSN COVID-19_FINAL.docx Supporting Statement B Uploaded 2024-10-29 Available
SSB 0920-1317 NHSN COVID-19_FINAL.docx Supporting Statement B Uploaded 2024-10-29 Repair queued
SSA 0920-1317 NHSN COVID 08JAN2025.docx Supporting Statement A Uploaded 2025-03-04 Available
SSA 0920-1317 NHSN COVID 08JAN2025.docx Supporting Statement A Uploaded 2025-03-04 Missing upstream
Change Memo 0920-1317 August 2024_FINAL_v2.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-08-22 Repair queued
Change Memo 0920-1317 August 2024_FINAL_v2.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-08-22 Missing upstream
Change Memo 0920-1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-08-06 Available
Change Memo 0920-1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-08-06 Missing upstream
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-04-26 Available
Change Request Memo NHSN COVID-19 0920-1317_26APR2024 v2.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-04-26 Missing upstream
Change Memo for CDC NHSN COVID-19 OMB Package 0920-1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-03-14 Repair queued
Change Memo for CDC NHSN COVID-19 OMB Package 0920-1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-03-14 Available
Resident Impact and Facility Capacity- csv temp..csv Supplementary Document Uploaded 2023-09-07 Available
Resident Impact and Facility Capacity- csv temp..csv Supplementary Document Uploaded 2023-09-07 Repair queued
TOI-Facility Importing COVID-19 and Respiratory Infections using a .csv file_RIFC.docx Supplementary Document Uploaded 2023-09-07 Available
TOI-Facility Importing COVID-19 and Respiratory Infections using a .csv file_RIFC.docx Supplementary Document Uploaded 2023-09-07 Missing upstream
Change Memo for NHSN September 2023_0920_1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2023-09-07 Available
Change Memo for NHSN September 2023_0920_1317.docx Justification for No Material/Nonsubstantive Change Uploaded 2023-09-07 Repair queued
Crosswalk_57.218.docx Supplementary Document Uploaded 2023-09-07 Available
Crosswalk_57.218.docx Supplementary Document Uploaded 2023-09-07 Repair queued
Crosswalk_57.144.docx Supplementary Document Uploaded 2023-09-07 Repair queued
Crosswalk_57.144.docx Supplementary Document Uploaded 2023-09-07 Repair queued
Crosswalk-COVID-19 Hospital Data.docx Supplementary Document Uploaded 2023-09-07 Available
Crosswalk-COVID-19 Hospital Data.docx Supplementary Document Uploaded 2023-09-07 Repair queued
Crosswalk 11.4 updated COVID JUNE_final.docx Supplementary Document Uploaded 2023-05-18 Available
Crosswalk 11.4 updated COVID JUNE_final.docx Supplementary Document Uploaded 2023-05-18 Repair queued
Change Memo for NHSN May 2023_0920_1317_final.docx Justification for No Material/Nonsubstantive Change Uploaded 2023-05-18 Repair queued
Change Memo for NHSN May 2023_0920_1317_final.docx Justification for No Material/Nonsubstantive Change Uploaded 2023-05-18 Repair queued
CDC Response to APIC Dec29 letter sk lw.docx Supplementary Document Uploaded 2023-03-06 Available
CDC Response to APIC Dec29 letter sk lw.docx Supplementary Document Uploaded 2023-03-06 Repair queued
5. NHSN - Report of End of Human Research Review 0.1253.docx Supplementary Document Uploaded 2022-11-28 Available
5. NHSN - Report of End of Human Research Review 0.1253.docx Supplementary Document Uploaded 2022-11-28 Repair queued
6. IRB Protocol Closure.pdf Supplementary Document Uploaded 2022-11-28 Available
6. IRB Protocol Closure.pdf Supplementary Document Uploaded 2022-11-28 Repair queued
3. Privacy Act Checklist 2022.docx Supplementary Document Uploaded 2022-11-28 Available
3. Privacy Act Checklist 2022.docx Supplementary Document Uploaded 2022-11-28 Missing upstream
1c. 42 USC 242m.PDF Supplementary Document Uploaded 2022-11-28 Available
1c. 42 USC 242m.PDF Supplementary Document Uploaded 2022-11-28 Repair queued
1b. 42 USC 242k.PDF Supplementary Document Uploaded 2022-11-28 Available
1b. 42 USC 242k.PDF Supplementary Document Uploaded 2022-11-28 Repair queued
1a. 42 USC 242b.PDF Supplementary Document Uploaded 2022-11-28 Available
1a. 42 USC 242b.PDF Supplementary Document Uploaded 2022-11-28 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
271955 57.510 COVID–19 Module Dialysis Outpatient Facility-CSV Form and Instruction Unchanged57.510 COVID–19 Module Dialysis Outpatient Facility-.csv
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 Unchanged57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_CSV
271950 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV Form and Instruction Unchanged
271935 57.155 Point of Care Testing Results - CSV Form and Instruction UnchangedPoint of Care Testing Results
271935 57.155 Point of Care Testing Results - CSV Form and Instruction Unchanged
270333 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) Form and Instruction Modified57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary_25SEP2025
270333 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) Form and Instruction ModifiedHealthcare Personnel COVID-19 Vaccination Cumulative Summary
270333 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) Form and Instruction Modified
270316 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction Modified57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025
270316 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction ModifiedWeekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (.csv)
270316 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction ModifiedWeekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities
270316 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) Form and Instruction Modified
270313 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv) Form and Instruction ModifiedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel 29SEP2025
270313 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv) Form and Instruction ModifiedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel
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 ModifiedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel_29SEP2025
270312 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) Form and Instruction ModifiedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel
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 ModifiedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form 57.216_rev 29SEP2025
270310 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv) Form and Instruction ModifiedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents
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 ModifiedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form 57.216_rev 29SEP2025
270309 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual) Form and Instruction ModifiedOptional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents
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 UnchangedHospital Respiratory Data Daily Reporting Form 14AUG2024
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 UnchangedHospital Respiratory Data Daily Reporting Form 14AUG2024
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 UnchangedHospital Respiratory Data Daily Reporting Form 14AUG2024
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 UnchangedHospital Respiratory Data Weekly Reporting Form
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 UnchangedHospital Respiratory Data Weekly Reporting Form
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 UnchangedHospital Respiratory Data Weekly Reporting Form
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 UnchangedPoint of Care Testing Results
266012 57.155 Point of Care Testing Results - Manual Form and Instruction Unchanged
249436 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual Form and Instruction UnchangedWeekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_Manual
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 Modified57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025
249435 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction ModifiedWeekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (manual)
249435 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction ModifiedWeekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities (manual)
249435 Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) Form and Instruction Modified
249434 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) Form and Instruction Modified57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary
249434 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) Form and Instruction ModifiedHealthcare Personnel COVID-19 Vaccination Cumulative Summary
249434 Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) Form and Instruction Modified
243719 57.510 COVID–19 Module Dialysis Outpatient Facility_Manual Form and Instruction UnchangedCOVID–19 Module - Dialysis Outpatient Facility
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 UnchangedNHSN Registration Form
243698 57.140 NHSN and Secure Access Management Services (SAMS) enrollment Form and Instruction Unchanged
ICR Details
0920-1317 202509-0920-004
Active 202502-0920-015
HHS/CDC 0920-25-0176
[NCEZID] National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 02/10/2026
Retrieve Notice of Action (NOA) 09/30/2025
  Inventory as of this Action Requested Previously Approved
01/31/2028 01/31/2028 01/31/2028
3,323,021 0 3,381,437
1,558,384 0 1,585,369
0 0 0
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 Change Request is submitted for 0920-01317 to update forms, following revised ACIP vaccine recommendations for COVID-19. There is a net decrease in burden hours associated with this Change Request.
US Code: 42 USC 242b, k, m Name of Law: U.S. Public Health Service Act (PHSA)
  
None
Not associated with rulemaking
  89 FR 47962 06/04/2024
89 FR 84146 10/21/2024
Yes
21
IC Title Form No. Form Name
57.101 Hospital Respiratory Data Form (Weekly - .csv import) 0920-1317 Hospital Respiratory Data Weekly Reporting Form
57.101 Hospital Respiratory Data Form (Weekly - API) 0920-1317 Hospital Respiratory Data Weekly Reporting Form
57.101 Hospital Respiratory Data Form (Weekly - User Entry) 0920-1317 Hospital Respiratory Data Weekly Reporting Form
57.102 - Hospital Respiratory Data Fomr (Daily - API) 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024
57.102 - Hospital Respiratory Data Form (Daily - user entry) 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024
57.102 Hospital Respiratory Data Form (Daily - .csv import) 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024
57.140 NHSN and Secure Access Management Services (SAMS) enrollment 0920-1317 NHSN Registration Form
57.155 Point of Care Testing Results - CSV 57.155 Point of Care Testing Results
57.155 Point of Care Testing Results - Manual 57.155 Point of Care Testing Results
57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities-.CSV 57.509 57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_CSV
57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual 57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_Manual
57.510 COVID–19 Module Dialysis Outpatient Facility-CSV 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility-.csv
57.510 COVID–19 Module Dialysis Outpatient Facility_Manual 57.510 COVID–19 Module - Dialysis Outpatient Facility
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (.csv) 57.217, 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel ,   Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel 29SEP2025
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) 57.217, 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel ,   Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel_29SEP2025
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (.csv) 57.216, 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents ,   Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form 57.216_rev 29SEP2025
Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual) 57.216, 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents ,   Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents Form 57.216_rev 29SEP2025
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (.csv) 57.219, 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary ,   57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary_25SEP2025
Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary (manual) 57.219, 57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary ,   57.219 Healthcare Personnel COVID-19 Vaccination Cumulative Summary
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (.csv) 57.218, 57.218, 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities ,   Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (.csv) ,   57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025
Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual) 57.218, Form 57.218, 57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities (manual) ,   Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF (manual) ,   57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of LTCF_25SEP2025
  Total Approved 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 3,323,021 3,381,437 0 -58,416 0 0
Annual Time Burden (Hours) 1,558,384 1,585,369 0 -26,985 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
Change Request for 0920-1317 includes modifications to four (4) forms. There is a net decrease in overall burden.
$49,992,135
Yes Part B of Supporting Statement
    Yes
    No
No
No
No
Yes
Jeffrey Zirger 404 639-7118 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
09/30/2025