OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Ebola Virus Disease in the United States:CDC Support for Case and Contact Investigation

ICR 201501-0920-006 · OMB 0920-1045 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
EVD Contact Tracing Investigation Form Form and Instruction New Available
EVD Case Investigation Form - United States Form and Instruction New Available
White House Evening Report Form and Instruction New Available
Symptom Monitoring Form - Environmental Lab Personnel Form and Instruction New Repair queued
EVD Tracking Form for Environmental Services Personnel Form and Instruction New Available
Symptom Monitoring Form - Lab Personnel Form and Instruction New Available
EVD Tracking Form for Laboratory Personnel Form and Instruction New Available
Symptom Monitoring Form - Health Care Workers Form and Instruction New Repair queued
EVD Tracking Form for Healthcare Workers with Direct Patient Contact Form and Instruction New Available
Symptom Monitoring Form Form and Instruction New Available
Ebola Virus Disease Person Under Investigation (PUI) Form Form and Instruction New Available
SupStmnt A US EVD CaseContInvest 20150123.docx Supporting Statement A Uploaded 2015-01-24 Repair queued
Appndx2b ASTHO cmmnts CDC response 14JAN2015.docx Supplementary Document Uploaded 2015-01-14 Available
Appndx2a CSTE cmmnts CDC rsponse 14JAN2015.docx Supplementary Document Uploaded 2015-01-14 Available
SupStmnt B US EVD CaseContInvest 20150123.docx Supporting Statement B Uploaded 2015-01-24 Available
Att7 Generic End-of-Monitoring Letter.docx Supplementary Document Uploaded 2015-01-09 Available
Att4b Info for HCWs Treating Ebola Patients.docx Supplementary Document Uploaded 2015-01-09 Available
Att4a Guidance for Contacts of Ebola Patients.docx Supplementary Document Uploaded 2015-01-09 Available
Att3cGuidance for Eval Triage of Ebola Contacts.docx Supplementary Document Uploaded 2015-01-09 Available
Att3b Guidance for Eval Triage of Ebola Contacts.docx Supplementary Document Uploaded 2015-01-09 Available
Att3a Guidance for HD DA-AM of Returned Travelers.docx Supplementary Document Uploaded 2015-01-09 Repair queued
Appndx3 SORN 09-20-0113 Epidemic Invest Case Records.pdf Supplementary Document Uploaded 2015-01-09 Available
Appndx1 42 USC 241 PH Service Act Section 301.pdf Supplementary Document Uploaded 2015-01-09 Repair queued
Appndx2c_NACCHOcomments.docx Supplementary Document Uploaded 2015-01-09 Available
IC Document Collections
IC IDCollectionTypeStatusForm
214741 EVD Contact Tracing Investigation Form Form and Instruction New
214740 EVD Case Investigation Form - United States Form and Instruction New
214557 White House Evening Report Form and Instruction New
214556 Symptom Monitoring Form - Environmental Lab Personnel Form and Instruction New
214555 EVD Tracking Form for Environmental Services Personnel Form and Instruction New
214554 Symptom Monitoring Form - Lab Personnel Form and Instruction New
214553 EVD Tracking Form for Laboratory Personnel Form and Instruction New
214552 Symptom Monitoring Form - Health Care Workers Form and Instruction New
214551 EVD Tracking Form for Healthcare Workers with Direct Patient Contact Form and Instruction New
214550 Symptom Monitoring Form Form and Instruction New
214548 Ebola Virus Disease Person Under Investigation (PUI) Form Form and Instruction New
ICR Details
0920-1045 201501-0920-006
Historical Active
HHS/CDC 15GW
Ebola Virus Disease in the United States:CDC Support for Case and Contact Investigation
New collection (Request for a new OMB Control Number)   No
Emergency 01/16/2015
Approved with change 01/26/2015
Retrieve Notice of Action (NOA) 01/14/2015
  Inventory as of this Action Requested Previously Approved
07/31/2015 6 Months From Approved
54,073 0 0
5,680 0 0
0 0 0
The CDC is seeking emergency OMB clearance to effectively complement its ongoing international and travel-related efforts for rapid case identification, contact tracing, and infection control of Ebola virus disease (EVD) in West Africa, now emerging within the US through travel-related routes. The CDC has developed a toolkit of standardized forms and guides for state, territorial, and local (STL) public health authorities to consider using whenever and wherever active monitoring for EVD must occur. These forms will be used whenever CDC is requested by STL public health authorities or by another federal agency to assist in the control and prevention of future EVD outbreaks. CDC has developed forms to collect case and contact information from several types of respondents that may require monitoring for EVD [general public including EVD cases, persons under investigation (PUI), contacts of an EVD case; healthcare workers (HCWs) with direct EVD patient contact; laboratory personnel; and environmental services personnel]. In addition, the CDC requests that STL public health authorities and their delegates provide daily reports of active surveillance updates to maintain situational awareness of EVD in the U.S.
This is an emergency request for 180-day OMB approval to allow the Centers for Disease Control and Prevention (CDC) to provide uninterrupted emergency support for domestic Ebola virus disease (EVD) case investigation and contact tracing activities on behalf of state, territorial, and local public health authorities in the United States (U.S.). As of December, 2014, continued federal assistance in West Africa indicates that domestic screening and monitoring of travelers from Ebola-affected countries and their contacts here in the U.S. remains a public health priority.
US Code: 42 USC 241 Name of Law: US Public Health Service Act
  
None
Not associated with rulemaking
No
  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 54,073 0 0 54,073 0 0
Annual Time Burden (Hours) 5,680 0 0 5,680 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
Submission 0920-15GW is a New ICR
$165,656
No
No
No
No
No
Uncollected
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.
01/14/2015