View Information Collection Request (ICR) Package
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IC List
Burden
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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:
201608-0920-012
Status:
Historical Active
Previous ICR Reference No:
201604-0920-011
Agency/Subagency:
HHS/CDC
Agency Tracking No:
16AGF
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:
08/18/2016
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/18/2016
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:
51
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 Mode of Transmission_Zika Virus among Utah Community Members, 2016
NA
Community Member Questionnaire
Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016
NA
Healthcare Professional Risk Assessment Questionnaire
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 agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016
NA, NA, NA, NA
GBS_Columbia Case Control Investigation Questionnaire - English
,
GBS_Columbia Case Control Investigation Questionnaire - Spanish
,
GBS_Columbia Chart Abstraction Form - English
,
GBS_Columbia Chart Abstraction Form - Spanish
Undetermined risk factors and modes of transmission for Shigella sonnei infection among residents of Genesee and Saginaw Counties – Michigan, 2016
NA
SHIGELLOSIS OUTBREAK CASE-CONTROL QUESTIONNAIRE - Gennessee/Saginaw Counties
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 E.coli O157 among visitors to a goat dairy--Connecticut, 2016
NA
Festival A Interview Form
Undetermined risk factors for Exophiala dermatitidis among oncology patients - New York City, 2016.
NA, NA
CDC Call Script
,
NYC Healthcare Worker Questionnaire
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
Undetermined source and risk factors for botulism among prisoners at a correctional facility - Mississippi, 2016
NA
Questionnaire for Prison Outreak of Clostridium Botulinum, June 2016
Undetermined source for Salmonella Infantis infections among detention center inmates - South Carolina, 2016
NA
Salmonella Infantis Infections among Detention Center Inmates - Case Interview Form
Undetermined source of Elizabethkingia anophelis infections among Wisconsin residents - Wisconsin, 2016
NA
Focus Group Discussion Guide
Undetermined source of Elizabethkingia meningoseptica bloodstream infection among Wisconsin residents - Wisconsin, 2016
NA
Elizabethkingia Meningoseptica Case Investigation Form
Undetermined source, mode of transmission, and risk factors for Candida auris infection - Colombia, 2016
NA, NA, NA, NA
Case Report Form - English
,
Case Report Form - Spanish
,
HealthCare Provider Interview
,
Patient Open-Ended Interview
Undetermined source, mode of transmission, and risk factors for Hepatitis A virus (HAV) transmission ‒ Hawaii, 2016
NA, NA
HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CASE QUESTIONNAIRE
,
HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CONTROL QUESTIONNAIRE
Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016
NA, NA, NA
Invasive GAS in LTCF 2016 - Employee Survey
,
Investigation of GAS outbreak in LTCF 2016 - Resident Record Extraction Form
,
Invasive GAS in Long Term Care Facility 2016 - Wound Care Survey
Undetermined sources and risk factors for a Rift Valley Fever Outbreak-Uganda, 2016
NA, NA
Risk Factor Questionnaire
,
Livestock Assessment Form
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Brazil, 2016
NA, NA
Survey Questionnaire
,
Chart Abstraction
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Puerto Rico, 2016
NA, NA
Zika Virus Disease Case Investigation Form
,
2016 Urgent Assessment of Blood Collection and Use in Puerto Rico in Response to the Zika Virus Outbreak
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection – American Samoa, 2016
NA
Zika Virus Disease Case Investigation Form
Undetermined transmission and risk factors for multidrug-resistant Mycobacterium tuberculosis among Tribal members - Arizona, 2016
NA, NA, NA
Case Abstraction Form
,
Case Interview Form
,
Contact Interview and Abstraction Form
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:
08/18/2016
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