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Federal forms, ICRs, and supporting documents

Information Collection Request

2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities

ICR 201410-0920-027 · OMB 0920-1033 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 0920-15CN Health Facility Assessment and Case Finding Survey Form and Instruction New Available
Form 0920-15CN Ebola Virus Disease Case Contact Questionnaire Form and Instruction New Available
Form 0920-15CN Viral Hemorrhagic Fever Contact Tracing Follow-Up Form Form and Instruction New Repair queued
Form 0920-15CN Viral Hemorrhagic Fever Contact Listing Form (Liberia) Form and Instruction New Repair queued
Form 0920-15CN Viral Hemorrhagic Fever Contact Listing Form (Guinea French) Form and Instruction New Repair queued
Form 0920-15CN Viral Hemorrhagic Fever Contact Listing Form (Senegal French) Form and Instruction New Repair queued
Form 0920-15CN Viral Hemorrhagic Fever Contact Listing Form (General) Form and Instruction New Repair queued
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Short Version Liberia) Form and Instruction New Repair queued
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Nigeria) Form and Instruction New Available
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Sierra Leone) Form and Instruction New Repair queued
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Liberia) Form and Instruction New Repair queued
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Senegal French) Form and Instruction New Repair queued
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Guinea French) Form and Instruction New Repair queued
Attachment O_Ebola Virus Epi Invest SORN_10-06-2014.doc Supplementary Document Uploaded 2014-10-23 Available
International_Ebola Emergency Clearance SSA Final.docx Supporting Statement B Uploaded 2014-10-23 Repair queued
International_Ebola Emergency Clearance SSA Final.docx Supporting Statement A Uploaded 2014-10-23 Available
IC Document Collections
IC IDCollectionTypeStatusForm
213621 Health Facility Assessment and Case Finding Survey Form and Instruction New
213620 Ebola Virus Disease Case Contact Questionnaire Form and Instruction New
213619 Viral Hemorrhagic Fever Contact Tracing Follow-Up Form Form and Instruction New
213618 Viral Hemorrhagic Fever Contact Listing Form (Liberia) Form and Instruction New
213617 Viral Hemorrhagic Fever Contact Listing Form (Guinea French) Form and Instruction New
213616 Viral Hemorrhagic Fever Contact Listing Form (Senegal French) Form and Instruction New
213615 Viral Hemorrhagic Fever Contact Listing Form (General) Form and Instruction New
213614 Viral Hemorrhagic Fever Case Investigation Form (Short Version Liberia) Form and Instruction New
213613 Viral Hemorrhagic Fever Case Investigation Form (Nigeria) Form and Instruction New
213612 Viral Hemorrhagic Fever Case Investigation Form (Sierra Leone) Form and Instruction New
213611 Viral Hemorrhagic Fever Case Investigation Form (Liberia) Form and Instruction New
213609 Viral Hemorrhagic Fever Case Investigation Form (Senegal French) Form and Instruction New
213607 Viral Hemorrhagic Fever Case Investigation Form (Guinea French) Form and Instruction New
ICR Details
0920-1033 201410-0920-027
Historical Active
HHS/CDC 0920-15CN
2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities
New collection (Request for a new OMB Control Number)   No
Emergency 10/24/2014
Approved without change 10/24/2014
Retrieve Notice of Action (NOA) 10/24/2014
  Inventory as of this Action Requested Previously Approved
04/30/2015 6 Months From Approved
297,850 0 0
54,279 0 0
0 0 0
On March 21, 2014, the World Health Organization (WHO) and the Ministry of Health (MoH) of Guinea reported an outbreak of Ebola viral disease (EVD), and shortly thereafter clinical cases were also reported in Liberia. By May, the first cases identified in Sierra Leone were reported. The outbreak expanded to Nigeria on July 25th and Senegal on August 29th. The outbreak continues to accelerate in West Africa and is unprecedented in size. This emergency ICR is an extension of several collections started under OMB Control Number 0920-1011, "Emergency Epidemic Investigation Data Collections," and will allow CDC to continue ongoing work.
WHO has declared the Ebola outbreak in West Africa to be an international public health emergency. The 2014 Ebola outbreak is unprecedented and the first in West Africa. CDC is currently assisting with the investigation, by taking active steps to respond to the rapidly changing situation internationally and domestically by working with other U.S. government agencies, the World Health Organization, and other domestic and international partners to identify sources and risk factors for Ebola infection in order to implement prevention and control measures. The epidemiological objectives are to maintain a centralized database for data collected from all outbreak sites, domestic and international to assist in contact tracing, case report collection, and patient or family interviews.
US Code: 42 USC 241 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
No
13
IC Title Form No. Form Name
Viral Hemorrhagic Fever Case Investigation Form (Senegal French) 0920-15CN Attachment C_Viral Hemorrhagic Fever Case Investigation Form_Senegal_French
Viral Hemorrhagic Fever Case Investigation Form (Liberia) 0920-15CN Attachment D_Viral Hemorrhagic Fever Case Investigation Form_Liberia (2)
Ebola Virus Disease Case Contact Questionnaire 0920-15CN Attachment L_Ebola Virus Disease Case Contact Questionnaire
Health Facility Assessment and Case Finding Survey 0920-15CN Attachment M_Health Facility Assessment and Case Finding Survey
Viral Hemorrhagic Fever Case Investigation Form (Guinea French) 0920-15CN Attachment B_Viral Hemorrhagic Fever Case Investigation Form_Guinea_French
Viral Hemorrhagic Fever Case Investigation Form (Sierra Leone) 0920-15CN Attachment E_Viral Hemorrhagic Fever Case Investigation Form_Sierra Leone
Viral Hemorrhagic Fever Case Investigation Form (Short Version Liberia) 0920-15CN Attachment G_Viral Hemorrhagic Fever Case Investigation Form_Short Version_Liberia
Viral Hemorrhagic Fever Case Investigation Form (Nigeria) 0920-15CN Attachment F_Viral Hemorrhagic Fever Case Investigation Form_Nigeria
Viral Hemorrhagic Fever Contact Listing Form (General) 0920-15CN Attachment H_Viral Hemorrhagic Fever Contact Listing Form_General
Viral Hemorrhagic Fever Contact Listing Form (Senegal French) 0920-15CN Attachment I_Viral Hemorrhagic Fever Contact Listing Form_Senegal_French
Viral Hemorrhagic Fever Contact Listing Form (Guinea French) 0920-15CN Attachment J_Viral Hemorrhagic Fever Contact Listing Form_Guinea_French
Viral Hemorrhagic Fever Contact Listing Form (Liberia) 0920-15CN Attachment K_Viral Hemorrhagic Fever Contact Listing Form_Liberia
Viral Hemorrhagic Fever Contact Tracing Follow-Up Form 0920-15CN Attachment N_Viral Hemorrhagic Fever Contact Tracing Follow-Up 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 297,850 0 0 297,850 0 0
Annual Time Burden (Hours) 54,279 0 0 54,279 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a New Emergency Clearance request
$339,695
No
No
No
No
No
Uncollected
Catina Conner 4046394775
  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.
10/24/2014