OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

ICR 201502-0920-002 · OMB 0920-0821 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Ebola Entry Screening Risk Assessment (Ill Traveler Interview) Form and Instruction New Repair queued
Ebola Entry Screening Risk Assessment - ARABIC Form and Instruction New Available
Ebola Entry Screening Risk Assessment - FRENCH Form and Instruction New Repair queued
Ebola Entry Screening Risk Assessment - ENGLISH Form and Instruction New Available
United States Traveler Health Declaration - ARABIC Form and Instruction New Available
United States Traveler Health Declaration - FRENCH Form and Instruction New Available
United States Traveler Health Declaration - ENGLISH Form and Instruction New Repair queued
Exposure Risk Assessment for Travelers from Ebola-Affected Countries Form Removed Repair queued
Air Travel Illness or Death Investigation Form Unchanged Available
Land Travel Illness or Death Investigation Form Unchanged Repair queued
Form 0920-0821 International Maritime Illness or Death Investigation Form and Instruction Unchanged Repair queued
0920-0821 Revision Part A 02102015 tracked.doc Supporting Statement A Uploaded 2015-02-10 Repair queued
Attachment B1 Comment to Federal Register 12022014.docx Supplementary Document Uploaded 2015-02-06 Repair queued
Attachment J Non-research Determination.pdf Supplementary Document Uploaded 2015-02-06 Available
Attachment B 60 day FRN 0821.pdf Supplementary Document Uploaded 2015-02-06 Available
Attachment A3 CFR-2013-title42-vol1-part71.pdf Supplementary Document Uploaded 2015-02-06 Repair queued
Attachment A2 CFR-2013-title42-vol1-part70.pdf Supplementary Document Uploaded 2015-02-06 Available
Attachment A1 USCODE-2009-title42-chap6A-subchapII-partG.PDF Supplementary Document Uploaded 2015-02-06 Repair queued
0920-0821 Revision Part B 02042015 tracked.docx Supporting Statement B Uploaded 2015-02-06 Available
IC Document Collections
IC IDCollectionTypeStatusForm
214908 Ebola Entry Screening Risk Assessment (Ill Traveler Interview) Form and Instruction New
214903 IVR Active Monitoring Survey - ARABIC (for translation service) Other-IVR Telephone Survey Script (Limited number - English for New
214902 IVR Active Monitoring Survey - FRENCH Other-IVR Telephone Survey Script - French New
214901 IVR Active Monitoring Survey - ENGLISH Other-IVR Telephone Survey Script - English New
214898 Ebola Entry Screening Risk Assessment - ARABIC Form and Instruction New
214896 Ebola Entry Screening Risk Assessment - FRENCH Form and Instruction New
214895 Ebola Entry Screening Risk Assessment - ENGLISH Form and Instruction New
214893 United States Traveler Health Declaration - ARABIC Form and Instruction New
214890 United States Traveler Health Declaration - FRENCH Form and Instruction New
214888 United States Traveler Health Declaration - ENGLISH Form and Instruction New
213021 Exposure Risk Assessment for Travelers from Ebola-Affected Countries Form Removed
188000 Air Travel Illness or Death Investigation Form Unchanged
187999 Land Travel Illness or Death Investigation Form Unchanged
187997 International Maritime Illness or Death Investigation Form and Instruction Unchanged
ICR Details
0920-0821 201502-0920-002
Historical Active 201409-0920-006
HHS/CDC 19217
Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing
Revision of a currently approved collection   No
Regular
Approved without change 04/10/2015
Retrieve Notice of Action (NOA) 02/11/2015
This ICR is approved for one year -- justification related to a public health need will need to be provided at that time for continued use of the Ebola screening forms. If CDC stops using them during this year, they should submit a change request ending their use.
  Inventory as of this Action Requested Previously Approved
04/30/2016 36 Months From Approved 08/31/2015
1,129,429 0 3,858
85,382 0 319
0 0 0
Quarantine station staff work in partnership with international, federal, state, and local agencies and organizations to fulfill their mission to reduce morbidity and mortality among immigrants, refugees, travelers, expatriates, and other globally mobile persons. This request for change is to add the Exposure Risk Assessment for Travelers from Ebola Outbreak-Affected countries.
US Code: 42 USC 264 Name of Law: Regulations to Control Communicable Diseases
   US Code: 42 USC 71 Name of Law: Foreign Quarantine
   US Code: 42 USC 70 Name of Law: Interstate Quarrantine
  
None
Not associated with rulemaking
  79 FR 71430 12/02/2014
80 FR 7474 02/10/2015
Yes
13
IC Title Form No. Form Name
United States Traveler Health Declaration - ENGLISH None, None, None United States Traveler Health Declaration - English/Hard Copy ,   United States Traveler Health Declaration - English/Portal ,   United States Health Declaration - English/PDF
United States Traveler Health Declaration - ARABIC None United States Traveler Health Declaration - Arabic Translation Guide
Ebola Entry Screening Risk Assessment - ENGLISH None Ebola Entry Screening Risk Assessment Form - English
Ebola Entry Screening Risk Assessment - FRENCH None Ebola Entry Screening Risk Assessment Form - French
Ebola Entry Screening Risk Assessment - ARABIC None Ebola Entry Screening Risk Assessment Form - Arabic
IVR Active Monitoring Survey - FRENCH
Ebola Entry Screening Risk Assessment (Ill Traveler Interview) None, None, None Ebola Entry Screening Risk Assessment Form - English ,   Ebola Entry Screening Risk Assessment Form - French ,   Ebola Entry Screening Risk Assessment Form - Arabic
Air Travel Illness or Death Investigation none Air Travel Illness or Death Investigation
International Maritime Illness or Death Investigation 0920-0821 Attachment A Maritime investigation form
Land Travel Illness or Death Investigation none Land Travel Illness or Death Investigation
Exposure Risk Assessment for Travelers from Ebola-Affected Countries none Risk Assessment for Travelers from Ebola-Affected Countries
United States Traveler Health Declaration - FRENCH None United States Traveler Health Declaration - French Translation Guide
IVR Active Monitoring Survey - ENGLISH
IVR Active Monitoring Survey - ARABIC (for translation service)
  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 1,129,429 3,858 0 1,125,571 0 0
Annual Time Burden (Hours) 85,382 319 0 85,063 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
Revision to 0920-0821 requests addition of tools to collect contact information for and assess the risk for Ebola in travelers coming to the United States from certain countries, as well as the addition of tools to assist in active monitoring of these travelers after they arrive in the United States.
$31,101,851
Yes Part B of Supporting Statement
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.
02/11/2015