All Age Influenza Hospitalization Surveillance Project

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 7 Adult Discharge Audit Form D: Future	Form	New	Available
Form 6 Adult Discharge Audit Form C: Summary	Form	New	Available
Form 5 Adult Discharge Audit Form B: Sampling Strategy	Form	New	Available
Form 4 Adult Discharge Audit Form A: Description of Matching Method	Form	New	Available
Form 3 Adult Discharge Audit Case Report Form	Form	New	Available
Form 2 Pediatric Influenza Hospitalization Surveillance Project	Form	New	Available
Form 1 Adult Influenza Hospitalization Surveillance Project Case	Form	New	Available
CDC Influenza Survey.doc	Supplementary Document	Uploaded 2009-03-23	Available
SS_Section B.doc	Supporting Statement B	Uploaded 2008-04-09	Available
30dy0808AB draft.doc	Supplementary Document	Uploaded 2008-04-09	Available
Attachment 20 Discharge Audit SchematicFinal21608.doc	Supplementary Document	Uploaded 2008-04-09	Available
Attachment 19 Adult SchematicFinal21608.doc	Supplementary Document	Uploaded 2008-04-09	Available
Attachment 18 Peds SchematicFinal21608.doc	Supplementary Document	Uploaded 2008-04-09	Available
Attachment 17 Example of Sampling StrategyFinal21608.doc	Supplementary Document	Uploaded 2008-04-09	Available
Attachment 16 adult consent formFinal21608.doc	Supplementary Document	Uploaded 2008-04-09	Available
Attachment 15 pediatric consent formFinal021608.doc	Supplementary Document	Uploaded 2008-04-09	Available
Attachment 14 Adult Flu Phone Script_Final21608.doc	Supplementary Document	Uploaded 2008-04-09	Available
Attachment 13 Peds Flu Phone Script_final21608.doc	Supplementary Document	Uploaded 2008-04-09	Available
Attachment 12 Adult IRB.doc	Supplementary Document	Uploaded 2008-04-09	Available
Attachment 10 References.doc	Supplementary Document	Uploaded 2008-04-09	Available
Attachment 2 60 Day FRN All_Flu_Hosp.pdf	Supplementary Document	Uploaded 2008-04-09	Available
Peds IRB exemption letter.pdf	Supplementary Document	Uploaded 2008-04-09	Available
SS_Section A 3.28 Final.doc	Supporting Statement A	Uploaded 2008-04-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
184761	Adult Discharge Audit Form D: Future	Form	New	Adult Discharge Audit Form D: Future
184760	Adult Discharge Audit Form C: Summary	Form	New	Adult Discharge Audit Form C: Summary
184759	Adult Discharge Audit Form B: Sampling Strategy	Form	New	Adult Discharge Audit Form B: Sampling Strategy
184758	Adult Discharge Audit Form A: Description of Matching Method	Form	New	Adult Discharge Audit Form A: Description of Matching Method
184757	Adult Discharge Audit Case Report Form	Form	New	Adult Discharge Audit Case Report Form
184756	Pediatric Influenza Hospitalization Surveillance Project	Form	New	Pediatric Influenza Hospitalization Surveillance Project
184755	Adult Influenza Hospitalization Surveillance Project Case	Form	New	Adult Influenza Hospitalization Surveillance Project Case

ICR Details

OMB Control No: 0920-0806	ICR Reference No: 200805-0920-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: All Age Influenza Hospitalization Surveillance Project
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/26/2009
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/02/2008
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved. At this time, OMB is not approving a sampling approach in the event of a large scale epidemic. Should there be circumstances under which sampling might be necesary CDC should seek to revise this collection. Additionally, OMB approves the influenza surveillance forms and the one time discharge audit consistent with CDC's statement included in the docket that data from the audit will not be "aggregated and annalyzed together." CDC is reminded that the PRA requires the Agency to seek and receive OMB approval for collections of information prior to initiating data collection.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2012	36 Months From Approved
Responses	2,027	0	0
Time Burden (Hours)	508	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The CDC is committed to achieving health promotion, disease prevention, and wellness objectives of "Healthy People 2010" and to obtaining population based surveillance data associated with Influenza related hospitalizations. This project addresses priority areas and surveillance goals in alignment with the CDC NCIRD performance goals to protect America's health.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 65965	11/26/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 20295	04/15/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Adult Discharge Audit Case Report Form	3	Adult Discharge Audit Case Report Form
Adult Discharge Audit Form A: Description of Matching Method	4	Adult Discharge Audit Form A: Description of Matching Method
Adult Discharge Audit Form B: Sampling Strategy	5	Adult Discharge Audit Form B: Sampling Strategy
Adult Discharge Audit Form C: Summary	6	Adult Discharge Audit Form C: Summary
Adult Discharge Audit Form D: Future	7	Adult Discharge Audit Form D: Future
Adult Influenza Hospitalization Surveillance Project Case	1	Adult Influenza Hospitalization Surveillance Project Case
Pediatric Influenza Hospitalization Surveillance Project	2	Pediatric Influenza Hospitalization Surveillance Project

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ICR Summary of Burden

table that charts list 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	2,027	0	0	2,027	0	0
Annual Time Burden (Hours)	508	0	0	508	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: NEW ICR

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Annual Cost to Federal Government: $2,141,664

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 05/02/2008

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