View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Multistate outbreak of coccidioidomycosis (Valley fever) in U.S. students and adults who traveled to Tijuana area, Mexico	Agency IC Tracking Number:

IC Status: Unchanged

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	Appendix1_Questionnaire.doc	NA	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

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

Number of Respondents: 45	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	45	0	0	0	0	45
Annual IC Time Burden (Hours)	15	0	0	0	0	15
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Investigation Request Memo	Investigation request - Valley fever - PRA application.pdf	11/30/2018
Burden Memo Email	0920-1011 GenIC Burden Memo Email.msg	11/30/2018
0920-1011 GenIC Request	2019002-XXX Valley Fever_Multi.docx	11/30/2018

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