Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
ABCs Case Report Form Modified 8090 2697 0 Form and Instruction 0920-0978 ABC Surveillance Case Report
ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form Modified 60 10 0 Form and Instruction 0920-0978 ABC H. Influenzae Neonatal Sepsis Expanded Surveillance Form
ABCs Invasive Pneumococcal Disease in Children Modified 220 37 0 Form and Instruction 0920-0978 ABC Invasive Pneumococcal Disease in Children
ABCs Neonatal Infection Expanded Tracking Form Modified 370 123 0 Form and Instruction 0920-0978 ABC Neonatal Infection Expanded Tracking Form
ABCs Severe GAS Infection Supplemental Form Modified 1360 453 0 Form and Instruction 0920-0978 ABC Severe GAS Infection Supplemental Form
Flu Surv NET Laboratory Survey New 230 38 0 Form and Instruction 0920-0978 FluSurv NET Lab Survey
FoodNet Campylobacter Modified 9420 3297 0 Form and Instruction 0920-0978 FoodNet Active Surveillance Variable List
FoodNet Cryptosporidium Removed 0 0 0 Form 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Cyclospora Modified 1630 272 0 Form and Instruction 0920-0978 FoodNet Active Surveillance Variable List
FoodNet Hemolytic Uremic Syndrome (HUS) Modified 100 100 0 Form and Instruction 0920-0978 FoodNet HUS CRF
FoodNet Listeria monocytogenes Modified 150 50 0 Form and Instruction 0920-0978 FoodNet Active Surveillance Variable List
FoodNet Salmonella Modified 7890 2761 0 Form and Instruction 0920-0978 FoodNet Active Surveillance Variable List
FoodNet Shiga toxin producing E. coli Modified 2050 683 0 Form and Instruction 0920-0978 FoodNet Active Surveillance Variable List
FoodNet Shigella Modified 2130 355 0 Form and Instruction 0920-0978 FoodNet Active Surveillance Variable List
FoodNet Vibrio Modified 340 56 0 Form and Instruction 0920-0978 FoodNet Active Surveillance Variable List
FoodNet Yersinia Modified 480 80 0 Form and Instruction 0920-0978 FoodNet Active Surveillance Variable List
Foodnet Clinical Laboratory Practices and Testing Volume New 700 233 0 Form and Instruction 0920-0978 Foodnet Lab Practices Volume
HAIC CDI Annual Laboratory Survey New 160 27 0 Form and Instruction 0920-0978 CDI Lab Survey
HAIC CDI Annual Surveillance Officers Survey New 10 3 0 Form and Instruction 0920-0978 CDI SO Annual Survey
HAIC CDI Case Report Form Modified 16500 9625 0 Form and Instruction 0920-0978 CDI Case Report Form
HAIC CDI LTCF Survey New 450 38 0 Form and Instruction 0920-0978 CDI LTCF Call script survey
HAIC Candidemia Case Report Form Modified 7200 2400 0 Form and Instruction 0920-0978 Candidemia Case Report
HAIC Candidemia Periodic Laboratory Survey New 135 45 0 Form and Instruction 0920-0978 Candidemia Laboratory Survey
HAIC Invasive Methicillin-Sensitive Staphylococcus aureus (MSSA) Modified 7540 3142 0 Form and Instruction 0920-0978 HAIC Invasive Methicillin-sensitive Staphylococcus aureus (MSSA)
HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Modified 4740 1975 0 Form and Instruction 0920-0978 HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA)
HAIC Invasive Staphylococcus aureus Annual Laboratory Survey New 110 15 0 Form and Instruction 0920-0978 Invasive Staph aureus Lab Survey
HAIC Invasive Staphylococcus aureus Annual Surveillance Officers Survey New 10 2 0 Form and Instruction 0920-0978 MRSA SO Supplemental Survey
HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB) Modified 5000 2083 0 Form and Instruction 0920-0978 HAIC Multi-site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB)
HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Modified 12000 5000 0 Form and Instruction 0920-0978 HAIC Multi-site Gram-Negative Surveillance Initiative – Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae (MuGSI-ESBL)
Influenza Hospitalization Surveilance Network Case Report Form Modified 10000 4167 0 Form and Instruction 0920-0978 FluSurv Net CRF
Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Modified 3330 278 0 Form and Instruction 0920-0978 FluSurv Net Provider Vaccination History Fax Form
Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English) Modified 3330 278 0 Form and Instruction 0920-0978 FluSurv NET Vaccination Phone Script
Form and Instruction 0920-0978 FluSurv NET Consent From English
Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish) Modified 3330 278 0 Form and Instruction 0920-0978 FluSurv NET Vaccination Phone Script
Form and Instruction 0920-0978 FluSurv NET Consent Form Spanish
Total burden requested under this ICR: 109065 40601 0  
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