OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 201601-0920-011 · OMB 0920-0821 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Ebola Entry Screening Risk Assessment (Ill Traveler Interview) Form and Instruction Removed Repair queued
Ebola Entry Screening Risk Assessment - ARABIC Form and Instruction Removed Available
Ebola Entry Screening Risk Assessment - FRENCH Form and Instruction Removed Repair queued
Ebola Entry Screening Risk Assessment - ENGLISH Form and Instruction Removed Available
United States Traveler Health Declaration - ARABIC Form and Instruction Removed Repair queued
United States Traveler Health Declaration - FRENCH Form and Instruction Removed Repair queued
United States Traveler Health Declaration - ENGLISH Form and Instruction Removed Repair queued
Air Travel Illness or Death Investigation Form Modified Available
Land Travel Illness or Death Investigation Form Modified Available
International Maritime Conveyance Illness or Death Investigation Form Form and Instruction Modified Available
0920-0821 Revision Part B 02182016.docx Supporting Statement B Uploaded 2016-02-22 Available
0920-0821 Revision Part A 02182016.doc Supporting Statement A Uploaded 2016-02-22 Available
Attachment G Non-research Determination.pdf Supplementary Document Uploaded 2016-02-22 Repair queued
Attachment B 60 Day FRN 0920-0821.pdf Supplementary Document Uploaded 2016-02-22 Repair queued
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
IC Document Collections
IC IDCollectionTypeStatusForm
214908 Ebola Entry Screening Risk Assessment (Ill Traveler Interview) Form and Instruction Removed
214903 IVR Active Monitoring Survey - ARABIC (for translation service) Other-IVR Telephone Survey Script (Limited number - English for Removed
214902 IVR Active Monitoring Survey - FRENCH Other-IVR Telephone Survey Script - French Removed
214901 IVR Active Monitoring Survey - ENGLISH Other-IVR Telephone Survey Script - English Removed
214898 Ebola Entry Screening Risk Assessment - ARABIC Form and Instruction Removed
214896 Ebola Entry Screening Risk Assessment - FRENCH Form and Instruction Removed
214895 Ebola Entry Screening Risk Assessment - ENGLISH Form and Instruction Removed
214893 United States Traveler Health Declaration - ARABIC Form and Instruction Removed
214890 United States Traveler Health Declaration - FRENCH Form and Instruction Removed
214888 United States Traveler Health Declaration - ENGLISH Form and Instruction Removed
188000 Air Travel Illness or Death Investigation Form Modified
187999 Land Travel Illness or Death Investigation Form Modified
187997 International Maritime Conveyance Illness or Death Investigation Form Form and Instruction Modified
ICR Details
0920-0821 201601-0920-011
Historical Active 201502-0920-002
HHS/CDC 0920-0821
Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing
Revision of a currently approved collection   No
Regular
Approved with change 06/03/2016
Retrieve Notice of Action (NOA) 03/01/2016
This ICR is approved for 3 years as forms pertaining to Ebola screening have been removed from the collection and are no longer utilized.
  Inventory as of this Action Requested Previously Approved
06/30/2019 36 Months From Approved 06/30/2016
2,650 0 1,129,429
221 0 85,382
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 Revision is to remove Respondents and Burden Hours associated with the United States Traveler Health Declaration, Ebola Entry Risk Assessment Forms, and the IVR Active Monitoring Survey System. No changes in data fields or collection processes are requested for the Air Travel, Maritime Conveyance, or Land Travel Illness or Death Investigation forms.
US Code: 42 USC 71 Name of Law: Foreign Quarantine
   US Code: 42 USC 264 Name of Law: Regulations to Control Communicable Diseases
   US Code: 42 USC 70 Name of Law: Interstate Quarrantine
  
None
Not associated with rulemaking
  80 FR 78738 12/17/2015
81 FR 9198 02/24/2016
No
3
IC Title Form No. Form Name
Ebola Entry Screening Risk Assessment - FRENCH None Ebola Entry Screening Risk Assessment Form - French
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
IVR Active Monitoring Survey - ARABIC (for translation service)
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 - FRENCH None United States Traveler Health Declaration - French Translation Guide
Ebola Entry Screening Risk Assessment - ARABIC None Ebola Entry Screening Risk Assessment Form - Arabic
IVR Active Monitoring Survey - FRENCH
IVR Active Monitoring Survey - ENGLISH
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 Conveyance Illness or Death Investigation Form NA Maritime Conveyance Illness or Death Investigation Form 0821_0134
Land Travel Illness or Death Investigation none Land Travel Illness or Death Investigation
  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 2,650 1,129,429 0 -1,126,779 0 0
Annual Time Burden (Hours) 221 85,382 0 -85,161 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
Revisions to 0920-0821 include an increase in the number of respondents/burden hours for the Air Travel Illness or Death Investigation form, and a decrease in respondents/burden hours for the Maritime Conveyance Illness or Death Investigation and Land Travel Illness or Death Investigation forms. Additionally, US Traveler Health Declaration and Ebola Risk Assessment Forms, IVR Script and Ebola Screening Risk Assessment forms and also being removed. This results in a net decrease in overall respondents/burden hours.
$467,353
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.
03/01/2016