View Information Collection Request (ICR) Package
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Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View Generic ICR - OIRA Conclusion
OMB Control No:
0920-1011
ICR Reference No:
201511-0920-002
Status:
Historical Active
Previous ICR Reference No:
201507-0920-005
Agency/Subagency:
HHS/CDC
Agency Tracking No:
16AT
Title:
Emergency Epidemic Investigation Data Collections - Expedited Reviews
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
11/04/2015
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/04/2015
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
03/31/2017
03/31/2017
03/31/2017
Responses
36,000
0
36,000
Time Burden (Hours)
18,000
0
18,000
Cost Burden (Dollars)
0
0
0
Abstract:
CDC submits the quarterly inventory of forms and burden memos per agreement with OMB.
Authorizing Statute(s):
US Code:
42 USC 301
Name of Law: PHSA
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
78 FR 41930
07/12/2013
30-day Notice:
Federal Register Citation:
Citation Date:
78 FR 69854
11/21/2013
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
33
IC Title
Form No.
Form Name
20140006XXX Measles FSM
2014004XXX_Legionnaires' Disease_Alabama 2014
none, none
Record Abstraction
,
Interview Questionnaire
2014005XXX_DiarrhealDisease_AS
none, none
Medical Abstraction Form
,
Case Questionnaire
2014008-XXX Chikungunya_PR
none, none, none, none
Household Questionnaire
,
Individual Questionnaire
,
Case Report (English)
,
Case Report (Spanish)
2014009-XXX_Chikungunya_US Service Org Volunteers
2014010-XXX Ebola_Guinea
0920-1011, 0920-1011
Appendix 1- Case Investigation Form
,
Appendix 2- Contact Tracing Form
2014011-XXX Ebola_Liberia
none, none
Case Report Form
,
Contact Listing Form
2014012-XXX Resp Illness UC_CA
2014013-XXX_Resp Illness UAC_Multi
2014014-XXX Ebola_Sierra Leone
2014015-XXX_Parechovirus_Multi
none, none
Chart Abstraction
,
Family interview
2014016-XXX_Ebola_DRC
2014E003XXX_MERS-CoV_GA
none, none
Questionnaire for Passengers and Crew
,
Follow-up Questionnaire for Asymptomatic Passengers and Crew
BSI_CA
none, none, none
Chart Abstraction
,
Outpatient Dialysis Practices Survey
,
Reprocessing Observation Checklist
Burkholderia Investigation_LA
None
Risk Assessment for Primate Research Center Employees and Inspectors
CCRF_Georgia
none, none, none
Case Investigation
,
KAP Survey
,
Consent
Chikungunya_USVI
CDC 56.31 A REV. 06/2006
Dengue Case Investigation Report
Cholera_Kenya
None, None
Community Questionnaire
,
Healthcare Worker Questionnaire
Dengue_AZ
CDC56.31A
DENGUE Case Investigation Report
EEI Guillain-Barre Syndrome_Bahia Brazil
NA, NA, NA, NA
Case Control Questionnaire - GBS English
,
Case Control Questionnaire - GBS Portugese
,
Chart Abstraction Questionnaire - GBS English
,
Chart Abstraction Questionnaire - GBS Portugese
Ebola_TX
None, None
Appendix 1 - Ebola Case Investigation Form
,
Appendix 2 - Ebola Case Contact Questionnaire
Ebola_West Africa_2014
none, none, none
Observation Guide
,
Field Guide
,
Focus Group Guide
GAS_IL 2015
NA, NA
GAS_IL Medical Record Abstraction
,
GAS_IL Employee Questionnaire
Mucormycosis_Kansas
None, None
Infection Prevention and Control Questions for Investigation of Mucormycosis
,
Mucormycosis Data Abstraction Form
PA NTM
none, none
Interview Questions
,
Records Abstraction Information
Pediatric cluster of neurologic symptoms - Colorado
none, none
Medical Chart Abstraction
,
Family Interview Questionnaire
Pseudomonas NICU_CA
Qualitative Investigation of HIV Transmission in Southeastern Indiana, 2015
NA
HIV Risk Factors Interview Guide
Tainted Beverage_Mozambique
Undetermined Source of an outbreak of Legionnaires' Disease among Hotel A Visitors - Hannibal, MO 2015
NA, NA
Legionella Environmental Assessment Form
,
Sample Data Sheet
Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015
NA, NA, NA, NA, NA, NA, NA, NA
Community Suyrvey - English
,
Community Survey - French
,
Medical Providers Interview Survey - English
,
Medical Providers Interview Survey - French
,
Rabies Official Interview Survey - English
,
Rabies Official Interview Survey - French
,
Public Health Official Interview Survey - English
,
Public Health Official Interview Survey - French
Undetermined risk factors for ocular syphilis - North Carolina, 2015
NA, NA
Abstraction Form
,
Interview Form
Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015.
NA, NA, NA, NA
Community Assessment
,
Community Assessment - Spanish
,
Healthcare Worker Assessment
,
Healthcare Worker Assessment
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
36,000
36,000
0
0
0
0
Annual Time Burden (Hours)
18,000
18,000
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
This is a new generic information collection request.
Annual Cost to Federal Government:
$1,510,099
Does this IC contain surveys, censuses, or employ statistical methods?
Yes
Part B of Supporting Statement
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Shari Steinberg 404 639-4942 sxw2@cdc.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
11/04/2015
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