Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
ABCs Case Report Form Unchanged 8090 2697 0 Form and Instruction 17AHK Att. 1 - 2017 ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT
ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form Unchanged 60 10 0 Form and Instruction 17AHK Att. 2 - ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form_HiNSES
ABCs Invasive Pneumococcal Disease in Children Unchanged 220 37 0 Form and Instruction 17AHK Att. 4 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) INVASIVE PNEUMOCOCCAL DISEASE IN CHILDREN
ABCs Neonatal Infection Expanded Tracking Form Unchanged 370 123 0 Form and Instruction 17AHK Att. 3 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) Neonatal Infection Expanded Tracking Form
ABCs Severe GAS Infection Supplemental Form Unchanged 1360 453 0 Form 0920-0978 ABCs - Severe GAS Infection: Supplemental Form
ABCs Surveillance for Non-Invasive Pneumococcal Pneumonia (SNiPP) Case Report Form Unchanged 1250 208 0 Form none Non Bacteremic Pneumococcal 2015
Form CDC 2016 Surveillance for Non-Invasive Penumococcal Pneumonia (SNiPP)
FoodNet Campylobacter Unchanged 8500 2975 0 Form 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Cryptosporidium Unchanged 1300 217 0 Form 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Cyclospora Unchanged 30 5 0 Form 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Hemolytic Uremic Syndrome (HUS) Unchanged 100 100 0 Form NA FoodNet Hemolytic Uremic Syndrome (HUS) Surveillance
FoodNet Listeria monocytogenes Unchanged 130 43 0 Form 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Salmonella Unchanged 8270 2895 0 Form 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Shiga toxin producing E. coli Unchanged 1900 633 0 Form 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Shigella Unchanged 2900 483 0 Form 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Vibrio Unchanged 250 42 0 Form 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Yersinia Unchanged 300 50 0 Form 0920-0978 FoodNet Variable List (site transmitted variables)
HAIC CDI Case Report Form Modified 16500 8250 0 Form 0920-0978 Clostridium Difficile Infection (CDI) Surveillance Emerging Infections Program Case Report
HAIC Candidemia Case Report Form Unchanged 7200 2400 0 Form and Instruction 0920-0978 CANDIDEMIA - CASE REPORT FORM
HAIC Invasive Methicillin-Sensitive Staphylococcus aureus (MSSA) Unchanged 10350 3450 0 Form and Instruction 0920-0978 Invasive Methicillin-Sensitive Staphylococcus aureus Healthcare-Associated Infections Community Interface (HAIC) Case Report – 2018
HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Unchanged 6090 2030 0 Form 0920-0978 Invasive Methicillin-Resistant Staphylococcus aureaus Healthcare-Associated Infections Community Interface(HAIC) Case Report - 2018
HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB) Unchanged 5000 1667 0 Form NA 2015 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report
Form VERSION:01-2016 2016 Multi-site Gram Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report
Form VERSION: 11/2017 2017 Multi-site Gram-Negative Surveillance Initiative (MuGSI) HAIC Case Report
Form 0920-09078 2018 Multi-Site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report
HAIC Multi-Site Gram-Negative Bacilli Case Report Form for Carbapenem-Resistant Pseudomonas ajeruginosa (CR-PA) Unchanged 3440 2580 0 Form 0920-0978 Carbapenem-resistant Pseudomonas aeruginosa Multi-Site Gram-Negative Surveillance (MuGSI) Case Report
HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Unchanged 12000 4000 0 Form and Instruction 0920-0978 Surveillance for Extended-Spectrum Beta- Lactamase-Producing Enterobacteriaceae Multi-Site Gram-Negative Bacilli Surveillance (MuGSI) Healthcare Associated Infection Community Interface (HAIC) CRF
Influenza Hospitalization Surveilance Network Case Report Form Unchanged 10000 4167 0 Form 0920-0978 2017-18 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Unchanged 3330 278 0 Form and Instruction 0920-0978 FluServ-NET Provider Vaccination History Fax Form
Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English) Unchanged 3330 278 0 Form and Instruction 0920-0978 FluServ-NET Consent Form - English
Form and Instruction 0920-0978 FluSurv-NET Vaccination Phone Script (English/Spanish)
Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish) Unchanged 3330 278 0 Form and Instruction 0920-0978 FluServ-NET Consent Form - Spanish
Form and Instruction 0920-0978 FluSurv-NET Vaccination Phone Script (English/Spanish)
Total burden requested under this ICR: 115600 40349 0  
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