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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0920-0821
ICR Reference No:
201601-0920-011
Status:
Historical Active
Previous ICR Reference No:
201502-0920-002
Agency/Subagency:
HHS/CDC
Agency Tracking No:
0920-0821
Title:
Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
06/03/2016
Retrieve Notice of Action (NOA)
Date Received in OIRA:
03/01/2016
Terms of Clearance:
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
Expiration Date
06/30/2019
36 Months From Approved
06/30/2016
Responses
2,650
0
1,129,429
Time Burden (Hours)
221
0
85,382
Cost Burden (Dollars)
0
0
0
Abstract:
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.
Authorizing Statute(s):
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
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:
80 FR 78738
12/17/2015
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 9198
02/24/2016
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
3
IC Title
Form No.
Form Name
Air Travel Illness or Death Investigation
none
Air Travel Illness or Death Investigation
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
Ebola Entry Screening Risk Assessment - ARABIC
None
Ebola Entry Screening Risk Assessment Form - Arabic
Ebola Entry Screening Risk Assessment - ENGLISH
None
Ebola Entry Screening Risk Assessment Form - English
Ebola Entry Screening Risk Assessment - FRENCH
None
Ebola Entry Screening Risk Assessment Form - French
IVR Active Monitoring Survey - ARABIC (for translation service)
IVR Active Monitoring Survey - ENGLISH
IVR Active Monitoring Survey - FRENCH
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
United States Traveler Health Declaration - ARABIC
None
United States Traveler Health Declaration - Arabic Translation Guide
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
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
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
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
Yes
Burden Reduction Due to:
Miscellaneous Actions
Short Statement:
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.
Annual Cost to Federal Government:
$467,353
Does this IC contain surveys, censuses, or employ statistical methods?
Yes
Part B of Supporting Statement
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
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 wtj5@cdc.gov
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:
03/01/2016
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