Contact investigation Outcome Reporting Forms

OMB Control No: 0920-0900	ICR Reference No: 201712-0920-005
Status: Historical Active	Previous ICR Reference No: 201609-0920-017
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0900-18GZ
Title: Contact investigation Outcome Reporting Forms
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/04/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/14/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2018	06/30/2018	06/30/2018
Responses	6,495	0	6,495
Time Burden (Hours)	786	0	786
Cost Burden (Dollars)	0	0	0

---

Abstract: CDC is requesting a Non-Substantive Change to 4 Forms (General, Measles, Rubella, TB) to allow the forms to be accessed regardless of individual HD network characteristics.

---

Authorizing Statute(s): US Code: 42 USC 264 Name of Law: The Public Health and Welfare    US Code: 42 USC 70-71 Name of Law: Quarantine, Inspection, Licensing

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 74099	12/15/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 9725	02/24/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 15

IC Title Form No. Form Name State/Local General Outcome Reporting (Land) none General Contact Reporting (Land) State/Local TB Outcoming Reporting (Air) 0920-0900 TB Air Contact Investigation Outcome Reportinig Form Cruise Ship TB Outcome Reporting - Maritime (Word & Excel) none, none TB Maritime Word ,   TB Maritime (Excel) State/Local Measles Outcome Reporting (Air) 0920-0900 Measles Air Contact Investigation Outcome Reporting Form Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel) none, none Measles Maritime (Word) ,   Measles Maritime (Excel) State/Local Rubella Outcome Reporting (Air) 0920-0900 Rubella Air Contact Investigation Outcome Reporting Form Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel) none, none Rubella Maritime (Word) ,   Rubella Maritime (Excel) Ebola Exposure Questionnaire for Flight Crew None Ebola Exposure Questionnaire for Flight Crew State/Local General Contact Reporting (Air) 0920-0900 General Air Contact Investigation Outcome Reporting Form Cruise Ship General Outcome Reporting -Maritime (Word & Excel) none, none General Reporting Maritime (Excel) ,   General Reporting Maritime (Word) Ebola Exposure Questionnaire for Airline Passengers None Ebola Exposure Questionnaire for Airline Passengers Ebola Exposure Questionnaire for Cleaning Crew None Ebola Exposure Questionnaire for Cleaninig Crew Ebola Exposure Questionnaire for Passengers on Other Commercial Conveyances None Ebola Exposure Questionnaire for Passengers of Other Commercial Conveyances Script for DGMQ HotLine - Introduction None Script for DGMQ HotLine - Introduction, Flight and Seat Confirmation Ebola Air Contact Investigation Ebola Exposure Questionnaire for Airport Staff None Ebola Exposure Questionnaire for Airport Staff

---

ICR Summary of Burden

	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	6,495	6,495	0	0	0	0
Annual Time Burden (Hours)	786	786	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $1,349,465

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Jeffrey Zirger 404 639-7118 [email protected]

---

Common Form ICR:  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:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(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;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
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.
Certification Date: 12/14/2017

---