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Serious adverse events, including deaths, of unknown etiology following ceftriaxone administration among patients in multiple healthcare facility types, AL and multiple states, September 2024-Present 0920-1011-25-0118
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0920-1011 CDC Case Report Form: Serious Adverse Events Following Ceftriaxone Injection in Healthcare Settings CDC Case Report Form - Serious Adverse Events Following Ceftriaxone Injection - Fillable.pdf N/A Yes Yes Paper Only

Disaster Management Emergency Response

 

90 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 120 0 120 0 0 0
Annual IC Time Burden (Hours) 60 0 60 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
0920-1011 EEI GenIC Request Memo Attach D_GenIC Request Form for EEI_Serious adverse events 24-25 extension 05092025.docx 05/12/2025
0920-1011 EEI Burden Memo Attach E_Burden Memo_serious adverse events24-25 extension 05092025.docx 05/12/2025
Non-Research Determination Non-research determination_Serioius Adverse Events Following Cefriaxone Injection.pdf 05/12/2025
Alabama DOH - Letter of Invitation_Extension ADPH_LOS_05_09_25.pdf 05/12/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.