OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

National Disease Surveillance Program - II. Disease Summaries

ICR 201304-0920-017 · OMB 0920-0004 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
0920-0004 Influenza Annual Survey 55.31A Form Modified Repair queued
Antiviral-Resistant Influenza infection Case Report Form Form and Instruction New Repair queued
CMRS Weekly - City Health Officer or Vital Statistics Registrars Form Modified Repair queued
CMRS Daily - City Health Officer or Vital Statistics Registrars Form Modified Available
Daily Influenza-like Illness year round Form Modified Repair queued
Daily Influenza-like Illness Oct - May Form Modified Available
Form 55.20 Weekly Influenza-like Illiness year round 55.20 Form Modified Repair queued
Form 55.20 Weekly Influenza-like Illness Oct - May 55.20 Form Modified Available
Influenza Associated Pediatric Death Case Report Form Form Modified Available
Influenza virus Internet Year-Round 55.31 Form Modified Repair queued
Influenza virus Internet Oct - May 55.31 Form Modified Repair queued
Influenza virus fax year-round 55.31 Form Modified Repair queued
Form Influenza Fax Influenza Virus Fax Oct-May 55.31 Form Modified Repair queued
Aggregate Hospitalization and Death Reporting Weekly Form Modified Repair queued
Possible Human Rabies - Patient Information Form Form Modified Repair queued
Human Infection with Novel Influenza A Virus Case Report Form Form Modified Repair queued
Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form Form Modified Available
Novel and Pandemic Influenza A Virus Infection Contact Trace Back Form Form Modified Repair queued
Novel and Pandemic Influenza A Virus Infection Case Investigation Form Form Modified Available
Daily Novel and Pandemic Influenza Virus State Case Status Summary Update Form Modified Repair queued
Brucellosis Case Report Form Form Modified Available
Babesiosis Case Report Form Form and Instruction Modified Available
Form No Number HABISS Monthly Reporting Form Form Modified Repair queued
Form No number HABISS Form Modified Available
Form CDC 52.12 0920-0004 Waterborne Diseases Outbreak 52.12 Form and Instruction Modified Repair queued
Form 55.28 Enhanced Animal Rabies Surveillance Monthly Report Form Modified Repair queued
Form CDC 52.13 0920-0004 Foodborne Outbreak 52.13 Form and Instruction Modified Repair queued
0920-0004 Arboviral Diseases Form and Instruction Modified Available
Form 1 0920-0004 Diarrheal Diseases Campylobacter Form Modified Available
Change Request OMB 0920-0004 4-5-13.docx Justification for No Material/Nonsubstantive Change Uploaded 2013-04-25 Repair queued
PHIN cover sheet.docx Supplementary Document Uploaded 2010-11-02 Available
PHLIP cover sheet.docx Supplementary Document Uploaded 2010-11-02 Available
Enhanced Animal Rabies Surveillance cover sheet.docx Supplementary Document Uploaded 2010-10-29 Repair queued
NORS Form.pdf Supplementary Document Uploaded 2008-12-22 Repair queued
FoodborneOutbreak Form 5213 ReportingInstructions.pdf Supplementary Document Uploaded 2007-01-17 Available
NREVSS PCR Worksheet CDC 55.83D.pdf Supplementary Document Uploaded 2007-01-17 Repair queued
NREVSS VI Worksheet CDC 55.83B.pdf Supplementary Document Uploaded 2007-01-17 Available
NREVSS EM Worksheet CDC 55.83C.pdf Supplementary Document Uploaded 2007-01-17 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
37707 0920-0004 Influenza Annual Survey 55.31A Form Modified
206690 Antiviral-Resistant Influenza infection Case Report Form Form and Instruction New
199058 CMRS Weekly - City Health Officer or Vital Statistics Registrars Form Modified
199057 CMRS Daily - City Health Officer or Vital Statistics Registrars Form Modified
199056 Daily Influenza-like Illness year round Form Modified
199055 Daily Influenza-like Illness Oct - May Form Modified
199054 Weekly Influenza-like Illiness year round 55.20 Form Modified
199053 Weekly Influenza-like Illness Oct - May 55.20 Form Modified
199052 Influenza Virus Electronic year round PHIN-MS Other-Variables for Reporting Modified
199051 Influenza Virus Electronic year round - PHLIP Other-Variables for electronic reporting Modified
199050 Influenza Associated Pediatric Death Case Report Form Form Modified
199049 Influenza virus Internet Year-Round 55.31 Form Modified
199048 Influenza virus Internet Oct - May 55.31 Form Modified
199047 Influenza virus fax year-round 55.31 Form Modified
199046 Influenza Virus Fax Oct-May 55.31 Form Modified
199045 Aggregate Hospitalization and Death Reporting Weekly Form Modified
199044 Possible Human Rabies - Patient Information Form Form Modified
199043 Human Infection with Novel Influenza A Virus Case Report Form Form Modified
199042 Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form Form Modified
199041 Novel and Pandemic Influenza A Virus Infection Contact Trace Back Form Form Modified
199040 Novel and Pandemic Influenza A Virus Infection Case Investigation Form Form Modified
199039 Daily Novel and Pandemic Influenza Virus State Case Status Summary Update Form Modified
199038 Brucellosis Case Report Form Form Modified
199037 Babesiosis Case Report Form Form and Instruction Modified
186749 HABISS Monthly Reporting Form Form Modified
186748 HABISS Form Modified
178375 0920-0004 Listeria Case Form Instruction Modified
178374 0920-0004 Suspected Viral Gastroenteritis (AKA Calicivirus Surveillance) Instruction Modified
178373 0920-0004 Cholera and Other Vibrio Illnesses 52.79 Instruction Modified
178372 0920-0004 Waterborne Diseases Outbreak 52.12 Form and Instruction Modified
178371 Enhanced Animal Rabies Surveillance Monthly Report Form Modified
178370 Rabies Monthly Report (paper) 55.28 Instruction Modified
178369 0920-0004 Foodborne Outbreak 52.13 Form and Instruction Modified
178365 0920-0004 National Respiratory and Enteric Virus Surveillance System NREVSS 55.83A-D Instruction Modified
178364 0920-0004 National Enterovirus Surveillance Report 55.9 Instruction Modified
178363 0920-0004 Arboviral Diseases Form and Instruction Modified
178362 0920-0004 Diarrheal Diseases Shigella Instruction Modified
178361 0920-0004 Diarrheal Diseases Salmonella Instruction Modified
178360 0920-0004 Diarrheal Diseases Campylobacter Form Modified
ICR Details
0920-0004 201304-0920-017
Historical Active 201108-0920-011
HHS/CDC 19323
National Disease Surveillance Program - II. Disease Summaries
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 04/29/2013
Retrieve Notice of Action (NOA) 04/25/2013
  Inventory as of this Action Requested Previously Approved
08/31/2014 08/31/2014 08/31/2014
292,656 0 292,485
56,222 0 56,136
0 0 0
This is a change request. Data on disease and preventable conditions are collected in accordance with jointly approved plans by the Center for Disease Control and Prevention and the Council of State and Territorial Health Epidemiologists. This change request involves a new disease form to be added and some edits to existing forms.
US Code: 42 USC 241 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
No
39
IC Title Form No. Form Name
0920-0004 Influenza Annual Survey 55.31A none Influenza Annual Survey
0920-0004 Diarrheal Diseases Campylobacter 1 Diarrheal Disease Surveillance Campylobacter
0920-0004 Diarrheal Diseases Salmonella
0920-0004 Diarrheal Diseases Shigella
0920-0004 Arboviral Diseases none Arboviral Diseases
0920-0004 National Enterovirus Surveillance Report 55.9
0920-0004 National Respiratory and Enteric Virus Surveillance System NREVSS 55.83A-D
0920-0004 Foodborne Outbreak 52.13 CDC 52.13 National Outbreak Reporting System
Rabies Monthly Report (paper) 55.28
Enhanced Animal Rabies Surveillance Monthly Report 55.28 Lab confirmed cases of rabies
0920-0004 Waterborne Diseases Outbreak 52.12 CDC 52.12 National Outbreak Reporting System: Waterborne Disease Transmission
0920-0004 Cholera and Other Vibrio Illnesses 52.79
0920-0004 Suspected Viral Gastroenteritis (AKA Calicivirus Surveillance)
0920-0004 Listeria Case Form
HABISS No number HABISS
HABISS Monthly Reporting Form No Number HABISS Report
Babesiosis Case Report Form none Babesiosis Case Report Form
Brucellosis Case Report Form none Brucellosis Case Report Form
Daily Novel and Pandemic Influenza Virus State Case Status Summary Update none Daily Case Status
Novel and Pandemic Influenza A Virus Infection Case Investigation Form none Influenza A Case Investigation
Novel and Pandemic Influenza A Virus Infection Contact Trace Back Form none Influenza A Trace Back
Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form none Trace Forward
Human Infection with Novel Influenza A Virus Case Report Form none Human Infection with Novel Influenza A Virus Case Report Form
Possible Human Rabies - Patient Information Form none Possible Human Rabies
Aggregate Hospitalization and Death Reporting Weekly none Aggregate Hospital
Influenza Virus Fax Oct-May 55.31 Influenza Fax WHO Fax Form
Influenza virus fax year-round 55.31 none WHO Fax Form
Influenza virus Internet Oct - May 55.31 none WHO Electronic
Influenza virus Internet Year-Round 55.31 none WHO Electronic Form
Influenza Associated Pediatric Death Case Report Form none Pediatric Death Case Report
Influenza Virus Electronic year round - PHLIP
Influenza Virus Electronic year round PHIN-MS
Weekly Influenza-like Illness Oct - May 55.20 55.20 Weekly Influenza-like Illness
Weekly Influenza-like Illiness year round 55.20 55.20 Weekly Influenza Like Illness
Daily Influenza-like Illness Oct - May none Influenza-like Illness Daily and year round
Daily Influenza-like Illness year round none Influenza-like illness Reporting
CMRS Daily - City Health Officer or Vital Statistics Registrars none CMRS Daily
CMRS Weekly - City Health Officer or Vital Statistics Registrars none CMRS Weekly
Antiviral-Resistant Influenza infection Case Report Form none Antiviral-Resistant Influenza infection Case Report Form
  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 292,656 292,485 0 171 0 0
Annual Time Burden (Hours) 56,222 56,136 0 86 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This change request entails a new disease form being added and a few edits to existing forms. The existing form Novel Human Influenza A Virus Infection Case Report Form title will change to Human Infection with Novel Influenza A Virus Case Report Form. The new form Antiviral-Resistant Influenza Infection Case Report Form will add 86 burden hours. See change justification for other nonmaterial/nonsubstantial changes.
$40,000
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Petunia Gissendaner 4046390164
  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.
04/25/2013