Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

Forms and Documents

Document Name	Status
Air Travel Illness or Death Investigation Form	Modified
Land Border Illness or Death Investigation Form	Modified
International Maritime Illness or Death Report Form	Modified
International Maritime Illness or Death Investigation Form	Modified
Q-station illness forms_IRB determination.pdf Supplementary Document	2009-09-17
Attachment L - RE public comment on federal register attached below in ful l- 08AW.htm Supplementary Document	2009-09-17
Attachment G - 60d FRN.pdf Supplementary Document	2009-09-17
Attachment F - Summary of Response Forms.doc Supplementary Document	2009-09-17
Attachment E - Quarantine_Station_Contact_List.pdf Supplementary Document	2009-09-17
Attachment D - 42cfr71.31Subpart D.pdf Supplementary Document	2009-09-17
Attachment C - Critieria for Ill Person Reporting- aviation.pdf Supplementary Document	2009-09-17
Attachment B - 42 CFR 71.pdf Supplementary Document	2009-09-17
Attachment A- Section 361 PHS Act.doc Supplementary Document	2009-09-17
Q Station Illness Forms Supporting Statement - May2009.doc Supporting Statement A	2009-09-17

IC Document Collections

IC ID	Document Title	Status
188000	Air Travel Illness or Death Investigation Form	Modified
187999	Land Border Illness or Death Investigation Form	Modified
187998	International Maritime Illness or Death Report Form	Modified
187997	International Maritime Illness or Death Investigation Form	Modified

ICR Details

OMB Control No: 0920-0821	ICR Reference No: 200909-0920-012
Status: Historical Active	Previous ICR Reference No: 200906-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/21/2009
	Date Received in OIRA: 09/17/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2012	36 Months From Approved
Responses	1,780	0	0
Time Burden (Hours)	171	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This data collection supports quarantine responsibilities of assessing, detecting, and responding to reports of communicable disease threats of potential public health importance at US ports of entry. The forms are for 3 types of ports of entry - air, maritime, and land/border. All forms collect pertinent demographic, clinical and epidemiological information on travelers suspected of being infected with a communicable disease and may be contagious during travel. The forms collect information for follow-up and tracking (surveillance) purposes.

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Authorizing Statute(s): US Code: 42 USC 361 Name of Law: Public Health Services 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:
	73 FR 20293	04/15/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 25556	05/28/2009
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Land Border Illness or Death Investigation	none	Land Border Illness or Death Investigation
Air Travel Illness or Death Investigation	none	Air Travel Illness or Death Reporting
International Maritime Illness or Death Investigation	none	International Maritime Illness or Death Investigation
International Maritime Illness or Death Report	none	International Maritime Illness or Death Report

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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	1,780	0	0	0	0	1,780
Annual Time Burden (Hours)	171	0	0	0	0	171
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:

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Annual Cost to Federal Government: $271,102

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

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)? No

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: 09/17/2009

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