Information Collection

Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016

IC 220680 under ICR 201601-0920-017 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Document Name Document Type
Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016 Form and Instruction
Invasive GAS in LTCF 2016 - Employee Survey Appendix 1. Invasive GAS in LTCF 2016 Employee Survey.docx Form and Instruction
Investigation of GAS outbreak in LTCF 2016 - Resident Re Appendix 2. Resident Record Extraction Form.docx Form and Instruction
Invasive GAS in Long Term Care Facility 2016 - Wound Car Appendix 3. Wound Care Survey.docx Form and Instruction
URGENT 0920-1011 GenIC Request GAS_Chicago_LTCF.msg Burden Memo Email IC Document
IDPH Epi-Aid Request Letter 03172016.pdf Letter of Invitation - IDPH IC Document
2016012-XXX_GAS_Chicago_LTCF.docx Emergency GenIC Request IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016	Agency IC Tracking Number:	16WB

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Electronic Capability
Form and Instruction	NA	Invasive GAS in LTCF 2016 - Employee Survey	Appendix 1. Invasive GAS in LTCF 2016 Employee Survey.docx	NA	No	Paper Only
Form and Instruction	NA	Investigation of GAS outbreak in LTCF 2016 - Resident Record Extraction Form	Appendix 2. Resident Record Extraction Form.docx	NA	No	Paper Only
Form and Instruction	NA	Invasive GAS in Long Term Care Facility 2016 - Wound Care Survey	Appendix 3. Wound Care Survey.docx	NA	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemic Investigation Case Records - SORN number 09-20-0113	FR Citation: 51 FR 42466

Number of Respondents: 365	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	443	443
Annual IC Time Burden (Hours)	151	151
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Burden Memo Email	URGENT 0920-1011 GenIC Request GAS_Chicago_LTCF.msg	03/18/2016
Letter of Invitation - IDPH	IDPH Epi-Aid Request Letter 03172016.pdf	03/18/2016
Emergency GenIC Request	2016012-XXX_GAS_Chicago_LTCF.docx	03/18/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.