Information Collection

Influenza Associated Pediatric Death Case Report Form

IC 195429 under ICR 201011-0920-006 · OMB 0920-0004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0004 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Influenza Associated Pediatric Death Case Report Form	Form
Pediatric Death Case Report Pediatric Flu.doc	Form

IC Title:

Influenza Associated Pediatric Death 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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Pediatric Death Case Report	Pediatric Flu.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 57

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 65 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	114	114
Annual IC Time Burden (Hours)	57	57
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.