Adult Discharge Audit Case Report Form

All Age Influenza Hospitalization Surveillance Project

Documents and Forms

Document Name Document Type
Form 3 Adult Discharge Audit Case Report Form Form
3 Adult Discharge Audit Case Report Form Attachment 5 Discharge Audit Case Report Form.doc Form

Information Collection (IC) Details

IC Title:	Adult Discharge Audit Case Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3	Adult Discharge Audit Case Report Form	Attachment 5 Discharge Audit Case Report Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	33	33
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.