OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Emergency Epidemic Investigation Data Collections - Expedited Reviews

ICR 201501-0920-020 · OMB 0920-1011 · Historical Inactive

Forms and Documents
DocumentTypeStatusAvailability
Mucormycosis_Kansas Form and Instruction Unchanged Available
CCRF_Georgia Form Unchanged Repair queued
Ebola_TX Form Unchanged Repair queued
Ebola_West Africa_2014 Form and Instruction Unchanged Repair queued
Pediatric cluster of neurologic symptoms - Colorado Form Unchanged Repair queued
BSI_CA Form Unchanged Repair queued
2014015-XXX_Parechovirus_Multi Form Unchanged Repair queued
2014011-XXX Ebola_Liberia Form Unchanged Repair queued
Form 0920-1011 2014010-XXX Ebola_Guinea Form and Instruction Unchanged Repair queued
2014008-XXX Chikungunya_PR Form Unchanged Repair queued
2014005XXX_DiarrhealDisease_AS Form Unchanged Repair queued
2014004XXX_Legionnaires' Disease_Alabama 2014 Form Unchanged Repair queued
2014E003XXX_MERS-CoV_GA Form Unchanged Repair queued
Appendix 1. Burden Memos.pdf Supplementary Document Uploaded 2015-01-21 Repair queued
Appendix 2. Data Collection Forms.pdf Supplementary Document Uploaded 2015-01-21 Repair queued
0920-1011 Non-Substantive Change Request Memo_Y1Q3.docx Justification for No Material/Nonsubstantive Change Uploaded 2015-01-21 Repair queued
2014012-XXX_Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Repair queued
2014010-XXX_Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Repair queued
2014008-XXX Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Available
2014007-XXX Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Repair queued
2014006-XXX Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Repair queued
2014005-XXX Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Repair queued
2014004-XXX Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Available
2014003-XXX_Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Available
Inventory.pdf Supplementary Document Uploaded 2014-10-29 Repair queued
EEI GenICR 0920-1011_Attach E _Burden Memo_9_16_2014.docx Supplementary Document Uploaded 2014-10-29 Repair queued
EEI GenICR 0920-0111_Attach D_Request for Approval 9-16-2014.docx Supplementary Document Uploaded 2014-10-29 Repair queued
EEI GenICR 0920-1011_Attach C_ Steps Conduct Emer Epi Invest_10_20_14.docx Supplementary Document Uploaded 2014-10-29 Repair queued
0920-1011 Non-Substantive Change Request Memo_revised.docx Justification for No Material/Nonsubstantive Change Uploaded 2014-10-29 Repair queued
EEI GenICR_Sup St B_3_20_14.docx Supporting Statement B Uploaded 2014-03-25 Repair queued
EEI GenICR 0920-13ZJ_App 6_Online Survey Case Finding Questionnaire_11-06-2013.docx Supplementary Document Uploaded 2013-11-20 Repair queued
EEI GenICR 0920-13ZJ_App 5_Phone Interview Questionnaire Patient_11-06-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Repair queued
EEI GenICR 0920-13ZJ_App 4_Q Fever Person Interview Questionnaire_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Repair queued
EEI GenICR 0920-13ZJ_App 3 _Hantav Pulm Synd Questionnaire_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Repair queued
EEI GenICR 0920-13ZJ_App 2_GBS Case Questionnaire_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Repair queued
EEI GenICR 0920-13ZJ_App 1_Chart Abstract Form_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Repair queued
EEI GenICR 0920-13ZJ_Attach H_Biospecimen Storage Consent_11-06-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Repair queued
EEI GenICR_0920-13ZJ_Attach G _Emer Epi Invest_IRB Letter_11-06-2013_Subm.pdf Supplementary Document Uploaded 2013-11-20 Repair queued
EEI Gen ICR 0920-13ZJ_Attach F_Epi Invest SORN_11-06-2013.doc Supplementary Document Uploaded 2013-11-20 Repair queued
EEI GenICR 0920-13ZJ_Attach E _Burden Memo_3-20-14.docx Supplementary Document Uploaded 2014-03-25 Repair queued
EEI_Attach D_Request for Approval_3_20_14.docx Supplementary Document Uploaded 2014-03-25 Repair queued
EEI GenICR 0920-13ZJ_Attach C_ Steps Conduct Emer Epi Invest_3_20_14.docx Supplementary Document Uploaded 2014-03-25 Repair queued
EEI GenICR_0920-13ZJ_Attach B _Emer Epi Invest_Pub 60-day FRN_11-06-2013_Subm.pdf Supplementary Document Uploaded 2013-11-20 Repair queued
EEI GenICR_0920-13ZJ_Attach A_Auth Legis Emer Epi Invest_11-06-2013_Subm.pdf Supplementary Document Uploaded 2013-11-20 Repair queued
EEI_GenICR_Sup St A_3_20_14.docx Supporting Statement A Uploaded 2014-03-25 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
214409 Mucormycosis_Kansas Form and Instruction Unchanged
214244 Dengue_AZ Other-WORD Unchanged
213373 CCRF_Georgia Form Unchanged
213323 Ebola_TX Form Unchanged
213274 Ebola_West Africa_2014 Form and Instruction Unchanged
213233 Pseudomonas NICU_CA Other-WORD Unchanged
213189 Pediatric cluster of neurologic symptoms - Colorado Form Unchanged
213101 BSI_CA Form Unchanged
212908 2014016-XXX_Ebola_DRC Other-WORD Unchanged
212644 2014015-XXX_Parechovirus_Multi Form Unchanged
212395 2014014-XXX Ebola_Sierra Leone Other-PDF Unchanged
212348 2014013-XXX_Resp Illness UAC_Multi Other-WORD Unchanged
212320 2014012-XXX Resp Illness UC_CA Other-WORD Unchanged
212266 2014011-XXX Ebola_Liberia Form Unchanged
212227 2014009-XXX_Chikungunya_US Service Org Volunteers Unchanged
212127 2014010-XXX Ebola_Guinea Form and Instruction Unchanged
211951 2014008-XXX Chikungunya_PR Form Unchanged
211894 Chikungunya_USVI Other-WORD Unchanged
211760 20140006XXX Measles FSM Other-WORD Unchanged
211705 2014005XXX_DiarrhealDisease_AS Form Unchanged
211702 2014004XXX_Legionnaires' Disease_Alabama 2014 Form Unchanged
211682 2014E003XXX_MERS-CoV_GA Form Unchanged
ICR Details
0920-1011 201501-0920-020
Historical Inactive 201410-0920-034
HHS/CDC 20989 15LX
Emergency Epidemic Investigation Data Collections - Expedited Reviews
No material or nonsubstantive change to a currently approved collection   No
Regular
Improperly submitted and continue 02/12/2015
Retrieve Notice of Action (NOA) 01/27/2015
  Inventory as of this Action Requested Previously Approved
03/31/2017 03/31/2017 03/31/2017
36,000 0 36,000
18,000 0 18,000
0 0 0
CDC submits the quarterly inventory of forms and burden memos per agreement with OMB.
US Code: 42 USC 301 Name of Law: PHSA
  
None
Not associated with rulemaking
  78 FR 41930 07/12/2013
78 FR 69854 11/21/2013
Yes
22
IC Title Form No. Form Name
Dengue_AZ CDC56.31A DENGUE Case Investigation Report
2014009-XXX_Chikungunya_US Service Org Volunteers
Pediatric cluster of neurologic symptoms - Colorado none, none Family Interview Questionnaire ,   Medical Chart Abstraction
CCRF_Georgia none, none, none Case Investigation ,   KAP Survey ,   Consent
Chikungunya_USVI CDC 56.31 A REV. 06/2006 Dengue Case Investigation Report
Pseudomonas NICU_CA
Ebola_TX None, None Appendix 1 - Ebola Case Investigation Form ,   Appendix 2 - Ebola Case Contact Questionnaire
2014E003XXX_MERS-CoV_GA none, none Questionnaire for Passengers and Crew ,   Follow-up Questionnaire for Asymptomatic Passengers and Crew
2014012-XXX Resp Illness UC_CA
2014010-XXX Ebola_Guinea 0920-1011, 0920-1011 Appendix 1- Case Investigation Form ,   Appendix 2- Contact Tracing Form
20140006XXX Measles FSM
2014011-XXX Ebola_Liberia none, none Case Report Form ,   Contact Listing Form
2014015-XXX_Parechovirus_Multi none, none Chart Abstraction ,   Family interview
2014014-XXX Ebola_Sierra Leone
2014004XXX_Legionnaires' Disease_Alabama 2014 none, none Record Abstraction ,   Interview Questionnaire
Mucormycosis_Kansas None, None Infection Prevention and Control Questions for Investigation of Mucormycosis ,   Mucormycosis Data Abstraction Form
Ebola_West Africa_2014 none, none, none Observation Guide ,   Field Guide ,   Focus Group Guide
BSI_CA none, none, none Chart Abstraction ,   Outpatient Dialysis Practices Survey ,   Reprocessing Observation Checklist
2014013-XXX_Resp Illness UAC_Multi
2014016-XXX_Ebola_DRC
2014005XXX_DiarrhealDisease_AS none, none Medical Abstraction Form ,   Case Questionnaire
2014008-XXX Chikungunya_PR none, none, none, none Household Questionnaire ,   Individual Questionnaire ,   Case Report (English) ,   Case Report (Spanish)
No
No
This is a new generic information collection request.
$1,510,099
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Shari Steinberg 404 639-4942 [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.
01/27/2015