View Information Collection (IC)
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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 Appendix 1: Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF) Appendix 1- Case_AdenoHepCRF_2022.07.01_CLEAN.docx NA No   Paper Only
Form and Instruction 0920-1011 Appendix 2: Pediatric Hepatitis of Unknown Etiology- Exposures Questionnaire (Parental Interview) Appendix 2- Case_AdenoHepExposuresQ_CLEAN.docx NA No   Paper Only
Form and Instruction 0920-1011 Appendix 3: Domestic Hepatitis-Adenovirus Investigation Consent Appendix 3- Case_Consent_Assent_HepatitisAdeno.docx NA No   Paper Only
Form and Instruction 0920-1011 Appendix 4: Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form: Controls (CRF) Appendix 4- Control_AdenoHepCRF_2022.07.01_CLEAN.docx NA No   Paper Only
Form and Instruction 0920-1011 Appendix 5: Pediatric Hepatitis of Unknown Etiology- Exposures Questionnaire: Controls (Parental Interview) Appendix 5- Control_AdenoHepExposuresQ_CLEAN.docx NA No   Paper Only
Form and Instruction 0920-1011 Appendix 6: Domestic Hepatitis-Adenovirus Investigation Consent: Controls (residual blood) Appendix 6- Control_Consent_Assent_HepatitisAdeno- residual blood.docx NA No   Paper Only
Form and Instruction 0920-1011 Appendix 7: Pediatric Hepatitis of Unknown Etiology- Exposures Questionnaire (Parental Interview) - SPANISH Appendix 7- Case_AdenoHepExposuresQ_CLEAN- Spanish.docx NA No   Paper Only
Form and Instruction 0920-1011 Appendix 8: Domestic Hepatitis-Adenovirus Investigation Consent - SPANISH Appendix 8- Case_Consent_Assent_HepatitisAdeno- Spanish.docx NA No   Paper Only

Health Public Health Monitoring

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

1,200 0
   
Individuals or Households
 
   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 1,200 0 1,200 0 0 0
Annual IC Time Burden (Hours) 667 0 667 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Burden Estimate Burden Estimate.docx 07/27/2022
CSTE Letter of Support CSTE letter of support_Hepatitis Adenovirus outbreak_4_25_22.pdf 07/27/2022
0920-1011 Emergency GenIC Request_July 2022 2022006-XXX HepatitisAdeno2_MultiState.docx 07/27/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.