OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Emergency Epidemic Investigation Data Collections - Expedited Reviews

ICR 201504-0920-005 · OMB 0920-1011 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Monkeypox_ROC Form New Available
Cholera_Kenya Form and Instruction New Repair queued
Burkholderia Investigation_LA Form and Instruction Unchanged Repair queued
Mucormycosis_Kansas Form and Instruction Unchanged Repair queued
CCRF_Georgia Form Unchanged Available
Ebola_TX Form Unchanged Repair queued
Ebola_West Africa_2014 Form and Instruction Unchanged Available
Pediatric cluster of neurologic symptoms - Colorado Form Unchanged Repair queued
BSI_CA Form Unchanged Available
2014015-XXX_Parechovirus_Multi Form Unchanged Repair queued
2014011-XXX Ebola_Liberia Form Unchanged Available
Form 0920-1011 2014010-XXX Ebola_Guinea Form and Instruction Unchanged Available
2014008-XXX Chikungunya_PR Form Unchanged Repair queued
2014005XXX_DiarrhealDisease_AS Form Unchanged Repair queued
2014004XXX_Legionnaires' Disease_Alabama 2014 Form Unchanged Available
2014E003XXX_MERS-CoV_GA Form Unchanged Repair queued
Appendix 1. Burden Memos.pdf Supplementary Document Uploaded 2015-04-22 Available
Appendix 2. Data Collection Forms.pdf Supplementary Document Uploaded 2015-04-22 Available
0920-1011 Non-Substantive Change Request Memo_Y1Q4_04-15-2015.docx Justification for No Material/Nonsubstantive Change Uploaded 2015-04-22 Available
0920-1011 Non-Substantive Change Request Memo_Y1Q3_03-02-2015.docx Justification for No Material/Nonsubstantive Change Uploaded 2015-03-03 Repair queued
Appendix 1. Burden Memos.pdf Supplementary Document Uploaded 2015-03-03 Available
Appendix 2. Data Collection Forms.pdf Supplementary Document Uploaded 2015-03-03 Available
2014012-XXX_Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Repair queued
2014010-XXX_Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Available
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 Available
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 Available
EEI GenICR 0920-1011_Attach E _Burden Memo_9_16_2014.docx Supplementary Document Uploaded 2014-10-29 Available
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 Available
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 Available
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 Available
EEI Gen ICR 0920-13ZJ_Attach F_Epi Invest SORN_11-06-2013.doc Supplementary Document Uploaded 2013-11-20 Available
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 Available
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 Available
EEI GenICR_0920-13ZJ_Attach A_Auth Legis Emer Epi Invest_11-06-2013_Subm.pdf Supplementary Document Uploaded 2013-11-20 Available
EEI_GenICR_Sup St A_3_20_14.docx Supporting Statement A Uploaded 2014-03-25 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
217356 Monkeypox_ROC Form New
217021 Cholera_Kenya Form and Instruction New
214996 Burkholderia Investigation_LA Form and Instruction Unchanged
214724 Tainted Beverage_Mozambique Other-WORD Unchanged
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 201504-0920-005
Historical Active 201502-0920-018
HHS/CDC 15AEG
Emergency Epidemic Investigation Data Collections - Expedited Reviews
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 06/12/2015
Retrieve Notice of Action (NOA) 06/09/2015
  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
26
IC Title Form No. Form Name
Tainted Beverage_Mozambique
CCRF_Georgia none, none, none Case Investigation ,   KAP Survey ,   Consent
2014016-XXX_Ebola_DRC
2014015-XXX_Parechovirus_Multi none, none Chart Abstraction ,   Family interview
20140006XXX Measles FSM
Burkholderia Investigation_LA None Risk Assessment for Primate Research Center Employees and Inspectors
2014010-XXX Ebola_Guinea 0920-1011, 0920-1011 Appendix 1- Case Investigation Form ,   Appendix 2- Contact Tracing Form
2014E003XXX_MERS-CoV_GA none, none Questionnaire for Passengers and Crew ,   Follow-up Questionnaire for Asymptomatic Passengers and Crew
Mucormycosis_Kansas None, None Infection Prevention and Control Questions for Investigation of Mucormycosis ,   Mucormycosis Data Abstraction Form
Chikungunya_USVI CDC 56.31 A REV. 06/2006 Dengue Case Investigation Report
Ebola_West Africa_2014 none, none, none Observation Guide ,   Field Guide ,   Focus Group Guide
Cholera_Kenya None, None Community Questionnaire ,   Healthcare Worker Questionnaire
BSI_CA none, none, none Chart Abstraction ,   Outpatient Dialysis Practices Survey ,   Reprocessing Observation Checklist
2014011-XXX Ebola_Liberia none, none Case Report Form ,   Contact Listing Form
2014009-XXX_Chikungunya_US Service Org Volunteers
2014008-XXX Chikungunya_PR none, none, none, none Household Questionnaire ,   Individual Questionnaire ,   Case Report (English) ,   Case Report (Spanish)
2014013-XXX_Resp Illness UAC_Multi
2014014-XXX Ebola_Sierra Leone
2014005XXX_DiarrhealDisease_AS none, none Medical Abstraction Form ,   Case Questionnaire
2014004XXX_Legionnaires' Disease_Alabama 2014 none, none Record Abstraction ,   Interview Questionnaire
2014012-XXX Resp Illness UC_CA
Pediatric cluster of neurologic symptoms - Colorado none, none Medical Chart Abstraction ,   Family Interview Questionnaire
Pseudomonas NICU_CA
Ebola_TX None, None Appendix 1 - Ebola Case Investigation Form ,   Appendix 2 - Ebola Case Contact Questionnaire
Dengue_AZ CDC56.31A DENGUE Case Investigation Report
Monkeypox_ROC none, none Survey iin English ,   Survey in French
  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 36,000 36,000 0 0 0 0
Annual Time Burden (Hours) 18,000 18,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
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.
06/09/2015