OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Surveillance Data Collections for Ebola Virus Disease in West Africa

ICR 201505-0920-008 · OMB 0920-1085 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Health Facility Assessment and Case Finding Study - Arabic Form and Instruction New Available
Health Facility Assessment and Case Finding Study - Portuguese Form and Instruction New Repair queued
Health Facility Assessment and Case Finding Study - French Form and Instruction New Available
Health Facility Assessment and Case Finding Study - English Form and Instruction New Available
Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone Form and Instruction New Available
Health Care Worker Ebola Virus Investigation Questionnaire - Liberia Form and Instruction New Repair queued
Health Care Worker EVD Exposure Risk - Arabic Form New Available
Health Care Worker EVD Exposure Risk - Portuguese Form New Available
Health Care Worker EVD Exposure Risk - French Form New Repair queued
Health Care Worker EVD Exposure Risk - English Form New Available
Ebola Sexual Transmission Investigation Form - Arabic Form and Instruction New Repair queued
Ebola Sexual Transmission Investigation Form - Portuguese Form and Instruction New Repair queued
Ebola Sexual Transmission Investigation Form - French Form and Instruction New Available
Ebola Sexual Transmission Investigation Form - English Form and Instruction New Available
EVD Case Contact Questionnaire - Arabic Form and Instruction New Available
EVD Case Contact Questionnaire - Portuguese Form and Instruction New Repair queued
EVD Case Contact Questionnaire - French Form and Instruction New Available
EVD Case Contact Questionnaire - English Form and Instruction New Repair queued
VHF Contact Tracing Follow-Up Form - Arabic Form New Repair queued
VHF Contact Tracing Follow-Up Form - Portuguese Form New Available
VHF Contact Tracing Follow-Up Form - French Form New Available
VHF Contact Tracing Follow-Up Form - English Form New Available
VHF Contact Listing Form - Arabic Form New Available
VHF Contact Listing Form - Portuguese Form New Available
VHF Contact Listing Form - French Form New Repair queued
VHF Contact Listing Form - English Form New Available
VHF Case Investigation Form - Arabic Form and Instruction New Available
VHF Case Investigation Form - Portuguese Form and Instruction New Available
VHF Case Investigation Form - French Form and Instruction New Available
VHF Case Investigation Form - English Form and Instruction New Repair queued
VHF Case Investigation (Short Form) - Arabic Form and Instruction New Repair queued
VHF Case Investigation (Short Form) - Portuguese Form and Instruction New Available
VHF Case Investigation (Short Form) - French Form and Instruction New Repair queued
VHF Case Investigation (Short Form) - English Form and Instruction New Available
SupStmnt A Survllnc Data Collctn EVD West Africa 20150621.docx Supporting Statement A Uploaded 2015-06-30 Repair queued
AppndxD West Africa Defn Burden Wage Est 20150621.docx Supplementary Document Uploaded 2015-06-29 Available
AppndxC EVDOutbrksChronology.pdf Supplementary Document Uploaded 2015-06-29 Available
AppndxC 2014 EVDGeoDistrbtn.pdf Supplementary Document Uploaded 2015-06-29 Available
AppndxB 60 day FRN 20150327.pdf Supplementary Document Uploaded 2015-06-29 Repair queued
AppndxA Auth Legisltn 42 CFR 241.pdf Supplementary Document Uploaded 2015-06-29 Available
SupStmnt B Survllnc Data Collctn EVD West Africa 20150621.docx Supporting Statement B Uploaded 2015-06-29 Available
IC Document Collections
IC IDCollectionTypeStatusForm
217290 Health Facility Assessment and Case Finding Study - Arabic Form and Instruction New
217289 Health Facility Assessment and Case Finding Study - Portuguese Form and Instruction New
217288 Health Facility Assessment and Case Finding Study - French Form and Instruction New
217287 Health Facility Assessment and Case Finding Study - English Form and Instruction New
217286 Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone Form and Instruction New
217285 Health Care Worker Ebola Virus Investigation Questionnaire - Liberia Form and Instruction New
217283 Health Care Worker EVD Exposure Risk - Arabic Form New
217282 Health Care Worker EVD Exposure Risk - Portuguese Form New
217281 Health Care Worker EVD Exposure Risk - French Form New
217280 Health Care Worker EVD Exposure Risk - English Form New
217279 Ebola Sexual Transmission Investigation Form - Arabic Form and Instruction New
217278 Ebola Sexual Transmission Investigation Form - Portuguese Form and Instruction New
217277 Ebola Sexual Transmission Investigation Form - French Form and Instruction New
217276 Ebola Sexual Transmission Investigation Form - English Form and Instruction New
217275 EVD Case Contact Questionnaire - Arabic Form and Instruction New
217274 EVD Case Contact Questionnaire - Portuguese Form and Instruction New
217273 EVD Case Contact Questionnaire - French Form and Instruction New
217272 EVD Case Contact Questionnaire - English Form and Instruction New
217270 VHF Contact Tracing Follow-Up Form - Arabic Form New
217269 VHF Contact Tracing Follow-Up Form - Portuguese Form New
217268 VHF Contact Tracing Follow-Up Form - French Form New
217263 VHF Contact Tracing Follow-Up Form - English Form New
217262 VHF Contact Listing Form - Arabic Form New
217261 VHF Contact Listing Form - Portuguese Form New
217260 VHF Contact Listing Form - French Form New
217259 VHF Contact Listing Form - English Form New
217253 VHF Case Investigation Form - Arabic Form and Instruction New
217252 VHF Case Investigation Form - Portuguese Form and Instruction New
217251 VHF Case Investigation Form - French Form and Instruction New
217250 VHF Case Investigation Form - English Form and Instruction New
217249 VHF Case Investigation (Short Form) - Arabic Form and Instruction New
217247 VHF Case Investigation (Short Form) - Portuguese Form and Instruction New
217246 VHF Case Investigation (Short Form) - French Form and Instruction New
217245 VHF Case Investigation (Short Form) - English Form and Instruction New
ICR Details
0920-1085 201505-0920-008
Historical Active
HHS/CDC 15UX
Surveillance Data Collections for Ebola Virus Disease in West Africa
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 09/14/2015
Retrieve Notice of Action (NOA) 07/13/2015
  Inventory as of this Action Requested Previously Approved
09/30/2018 36 Months From Approved
946,500 0 0
428,757 0 0
0 0 0
This is a request for a new OMB package that includes all of the forms for the International data collection for the Ebola virus disease response from 2014. This ICR will allow CDC to continue Ebola-related information collections beyond their current emergency expiration dates and to conduct newly proposed information collections within international borders of Ebola-affected countries.
US Code: 42 USC 241 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
  80 FR 16405 03/27/2015
80 FR 36994 06/29/2015
No
34
IC Title Form No. Form Name
Ebola Sexual Transmission Investigation Form - English None Ebola Sexual Transmission Investigation Form - English
Ebola Sexual Transmission Investigation Form - French None Ebola Sexual Transmission Investigation Form - French
Ebola Sexual Transmission Investigation Form - Portuguese None Ebola Sexual Transmission Investigation Form - Portuguese
Ebola Sexual Transmission Investigation Form - Arabic None Ebola Sexual Transmission Investigation Form - Arabic
Health Care Worker EVD Exposure Risk - English None Health Care Worker EVD Exposure Risk - English
Health Care Worker EVD Exposure Risk - French None Health Care Worker EVD Exposure Risk - French
Health Care Worker EVD Exposure Risk - Portuguese None Health Care Worker EVD Exposure Risk - Portuguese
Health Care Worker EVD Exposure Risk - Arabic None Health Care Worker EVD Exposure Risk - Arabic
Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone None Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone
Health Facility Assessment and Case Finding Study - English None Health Facility Assessment and Case Finding Study - English
Health Facility Assessment and Case Finding Study - French None Health Facility Assessment and Case Finding Study - French
Health Facility Assessment and Case Finding Study - Portuguese None Health Facility Assessment and Case Finding Study - Portuguese
Health Facility Assessment and Case Finding Study - Arabic None Health Facility Assessment and Case Finding Study - Arabic
VHF Case Investigation (Short Form) - English None VHF Case Investigation (Short Form) - English
VHF Case Investigation (Short Form) - French None VHF Case Investigation (Short Form) - French
VHF Case Investigation (Short Form) - Portuguese None VHF Case Investigation (Short Form) - Portuguese
VHF Case Investigation Form - French None VHF Case Investigation Form - French
VHF Contact Listing Form - English None VHF Contact Listing Form - English
VHF Contact Listing Form - French None VHF Contact Listing Form - French
VHF Contact Listing Form - Arabic None VHF Contact Listing Form - Arabic
VHF Contact Tracing Follow-Up Form - English None VHF Contact Tracing Follow-Up Form - English
Health Care Worker Ebola Virus Investigation Questionnaire - Liberia None Health Care Worker Ebola Virus Investigation Questionnaire - Liberia
VHF Case Investigation (Short Form) - Arabic None VHF Case Investigation (Short Form) - Arabic
VHF Case Investigation Form - English None VHF Case Investigation Form - English
VHF Case Investigation Form - Portuguese None VHF Case Investigation Form - Portuguese
VHF Case Investigation Form - Arabic None VHF Case Investigation Form - Arabic
VHF Contact Tracing Follow-Up Form - French None VHF Contact Tracing Follow-Up Form - French
VHF Contact Listing Form - Portuguese None VHF Contact Listing Form - Portuguese
VHF Contact Tracing Follow-Up Form - Portuguese None VHF Contact Tracing Follow-Up Form - Portuguese
VHF Contact Tracing Follow-Up Form - Arabic None VHF Contact Tracing Follow-Up Form - Arabic
EVD Case Contact Questionnaire - English None EVD Case Contact Questionnaire - English
EVD Case Contact Questionnaire - French None EVD Case Contact Questionnaire - French
EVD Case Contact Questionnaire - Portuguese None EVD Case Contact Questionnaire - Portuguese
EVD Case Contact Questionnaire - Arabic None EVD Case Contact Questionnaire - Arabic
  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 946,500 0 0 946,500 0 0
Annual Time Burden (Hours) 428,757 0 0 428,757 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
Submission of 0920-15UX is a New ICR and contains an increase in Burden Hours.
$3,707,498
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.
07/13/2015