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View Information Collection (IC)

View Information Collection (IC)

Undetermined agent for hepatitis among children <10 years of age – 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 Pediatric Hepatitis of Unknown Etiology Case Report Form Appendix 1 - Pediatric Hepatitis of Unknown Etiology - Case Report Form.docx NA No   Paper Only
Form and Instruction 0920-1011 Pediatric Hepatitis of Unknown Etiology Exposures Questionnaire Appendix 2 - Adenovirus Hepatitis Exposures Case Report Form (Parental Interview).docx NA No   Fillable Fileable
Form and Instruction 0920-1011 Consent Form Appendix 3 - Domestic Hepatitis-Adenovirus Investigation Consent.docx NA No   Fillable Fileable

Disaster Management Emergency Response

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

1,500 0
   
State, Local, and Tribal Governments
 
   0 %

  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 1,500 0 1,500 0 0 0
Annual IC Time Burden (Hours) 835 0 835 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Emergency GenIC Request 0920-1011 1. GenIC Request Form - EEI Generic ICR hepatitis unknown etiology.docx 04/26/2022
Burden Table - Email Template URGENT 0920-1011 GenIC Request Undetermined agent .msg 04/26/2022
CSTE Letter of Support CSTE letter of support_Hepatitis Adenovirus outbreak_4_25_22.pdf 04/26/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.