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[CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023 0920-0879-23AW
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 0920-0879 Pediatric Hepatitis - MEDICAL RECORD ABSTRACTION FORM Attachment A_Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form Controls_MarOMBupdate.docx NA Yes Yes Fillable Fileable
Form 0920-0879 Pediatric Hepatitis - Exposure Questionnaire Attachment B_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire [Parental Interview]_MarOMBupdate.docx NA Yes Yes Fillable Fileable
Form 0920-0879 Pediatric Hepatitis - Exposure Questionnaire (Spanish) Attachment C_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire CONTROL [Parental Interview]_MarOMBupdate.docx NA Yes Yes Fillable Fileable
Form 0920-0879 Pediatric Hepatitis - Exposure Questionnaire CONTROL Attachment D_Hepatitis pediátrica de etiología desconocida - Cuestionario sobre exposiciones (entrevista a los padres). Spanish tr_MarOMBupdate.docx NA Yes Yes Fillable Fileable
Form 0920-0879 Pediatric Hepatitis - Exposure Questionnaire CONTROL (Spanish) Attachment E_Hepatitis pediátrica de etiología desconocida. CONTROL del cuestionario sobre exposiciones (Entrevista a los padres)_MarOMBupdate.docx NA Yes Yes Fillable Fileable

Health Illness Prevention

 

156 0
   
State, Local, and Tribal Governments
 
   100 %

  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 520 0 520 0 0 0
Annual IC Time Burden (Hours) 390 0 390 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Summary Routine Calls Attachment F_Summary of Routine Calls.docx 11/04/2022
Supporting Statement A CSTLTS Generic Supporting_Statement_A_Guideline File_3Nov22_clean.docx 11/04/2022
Supporting Statement B CSTLTS Generic Supporting_Statement_B_Guideline File_3Nov2022_clean.docx 11/04/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.