Information Collection

Undetermined risk factors for long term sequela resulting from Rocky Mountain spotted fever-Arizona, 2018

IC 234030 under ICR 201810-0920-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-1011 Undetermined risk factors for long term sequela resulting from Rocky Mountain spotted fever-Arizona, 2018 Form and Instruction
0920-1011 Patient Screening Questionnaire Appendix 2. Patient Screening Questionnaire_7-19-2018.pdf Form and Instruction
0920-1011 Neurologic Exam Form Appendix 3. Neuro Exam Form.pdf Form and Instruction
Letter of Invitation.pdf Letter of Invitation IC Document
IRB Approval.pdf IRB Approval IC Document
2019001-XXX RMSF_AZ.docx 0920-1011 EEI GenIC Request IC Document
Burden Memo Email RMSF_AZ v2.msg Burden Memo Email IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Undetermined risk factors for long term sequela resulting from Rocky Mountain spotted fever-Arizona, 2018	Agency IC Tracking Number:	0920-1011-19EE

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1011	Patient Screening Questionnaire	Appendix 2. Patient Screening Questionnaire_7-19-2018.pdf	NA	No		Paper Only
Form and Instruction	0920-1011	Neurologic Exam Form	Appendix 3. Neuro Exam Form.pdf	NA	No		Paper Only

Line of Business: Disaster Management

Subfunction: Emergency Response

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

Number of Respondents: 1	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	1	1
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Letter of Invitation	Letter of Invitation.pdf	11/14/2018
IRB Approval	IRB Approval.pdf	11/14/2018
0920-1011 EEI GenIC Request	2019001-XXX RMSF_AZ.docx	11/14/2018
Burden Memo Email	Burden Memo Email RMSF_AZ v2.msg	11/14/2018

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