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Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022 0920-1011
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0920-1011 Aggregate counts of persons exposed to HPAI Appendix 1. Aggregate counts of persons exposed to highly pathogenic avian influenza (HPAI).docx NA Yes Yes Fillable Fileable
Form and Instruction 0920-1011 HPAI H5 Consent Form (English) Appendix 2. HPAIH5_ConsentForm_20220311_FINAL.docx NA No   Paper Only
Form and Instruction 0920-1011 HPAI H5 Consent Form (Spanish) Appendix 3. HPAIH5_ConsentForm_20220311_FINAL_SPANISH.docx NA No   Paper Only
Form and Instruction 0920-1011 Avian Influenza Initial Case Investigation Form (English) Appendix 4. HPAIH5_InitialCaseInvestigationForm_20220321_FINAL.docx NA No   Paper Only
Form and Instruction 0920-1011 Avian Influenza Initial Case Investigation Form (Spanish) Appendix 5. HPAIH5_InitialCaseInvestigationForm_20220321_FINAL_SPANISH.docx NA No   Paper Only
Form and Instruction 0920-1011 Highly Pathogenic Avian Influenza A (H5N1) Exposure Questionnaire (English) Appendix 6. HPAIH5_Questionnaire_20220324_FINAL.docx NA No   Paper Only
Form and Instruction 0920-1011 Highly Pathogenic Avian Influenza A (H5N1) Exposure Questionnaire (Spanish) Appendix 7. HPAIH5_Questionnaire_20220324_FINAL_SPANISH.docx NA No   Paper Only
Form and Instruction 0920-1011 HPAI H5 Self Swab Instructions (English) Appendix 8. HPAIH5_selfswabinstructions.pptx NA No   Paper Only
Form and Instruction 0920-1011 HPAI H5 Self Swab Instructions (Spanish) Appendix 9. HPAIH5_selfswabinstructions_SPANISH.pptx NA No   Paper Only
Form and Instruction 0920-1011 Human Sera Collection Guidelines for Flu Serology Appendix 10. LP-093Rev6D - Human Sera Collection Guidelines for Flu Serology.pdf NA No   Paper Only

Health Illness Prevention

Epidemic Investigation Case Records - SORN number 09-20-0113  51 FR 42466

650 0
   
State, Local, and Tribal Governments
 
   50 %

  Approved 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 7,800 0 7,800 0 0 0
Annual IC Time Burden (Hours) 199 0 199 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
0920-1011 Emergency GenIC Request Form 1. GenIC Request Form - EEI Generic ICR KT NML.docx 04/09/2022
0920-1011 - EEI GenIC - Burden Estimate 1. Burden Estimate_EEI Generic ICR 20220001-XXX.docx 04/09/2022
0920-1011 - EEI GenIC Terms of Use 1. Terms of Use - EEI Generic ICR NML.docx 04/09/2022
CSTE Letter of Support - signed CSTE Letter - signed.pdf 04/09/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.