Screening Form

Clostridium difficile Infection (CDI) Surveillance

OMB: 0920-0892

IC ID: 198153

Information Collection (IC) Details

View Information Collection (IC)

Screening Form
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction New form Attachment E Screening Questions for CDI Attachment E - Screening Questions for Clostridium difficile Telephone Interview.doc No No Fillable Printable

Health Illness Prevention

 

600 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 600 0 600 0 0 0
Annual IC Time Burden (Hours) 50 0 50 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment D CDI Assent Attachment D _ CDI ASSENT for 13-15 .doc 06/16/2011
Attachment C Adult Verbal Consent Attachment C _ADULT VERBAL CONSENTrevised.doc 06/16/2011
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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