Information Collection

Influenza Hospitalization Surveilance Network Case Report Form

IC 207651 under ICR 201803-0920-010 · OMB 0920-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0978 Influenza Hospitalization Surveilance Network Case Report Form Form
0920-0978 2017-18 FluSurv-NET Influenza Hospitalization Surveillan 11- 2017-18 FluSurv-NET Case Report Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Influenza Hospitalization Surveilance Network Case Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-0978	2017-18 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form	11- 2017-18 FluSurv-NET Case Report Form.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,000	6,000	4,000
Annual IC Time Burden (Hours)	4,167	3,167	1,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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