Document Name Document Type
SHD Reporting (14EU) and Testing Practices and TB Elimination FOA (14GS) Form
Survey for Epidemiologist Attachment F Campy Data Collection Epi Instrument (online version) 12 13 13.docx Form
Survey for Microbiolgist Attachment K Campy Data Collection Lab Instrument (online version) 12 13 13.docx Form
TB Instrument - Web ATTACHMENT B- Data Collection Instrument_Online Version docx.docx Form
Attachement A Winnable battles 12 12 13.pdf Attachment A Winnable battles 12 12 13 IC Document
Attachment B NNDSS website 12 12 13.pdf Attachment B NNDSS website 12 12 13 IC Document
Attachment C LEDS website 12 12 13.pdf Attachment C LEDS website 12 12 13 IC Document
Attachment D FoodNet website 12 12 13.pdf Attachment D FoodNet website 12 12 13 IC Document
Attachment G Introductory Email_Epi.docx Email - Epi IC Document
Attachment L Introductory Email_Lab.docx Email - Lab IC Document
Attchment H 7 day follow up email_Epi.docx Attachment H 7 day follow up email_Epi IC Document
Attachment M 7 day follow up email_Lab.docx Attachment M 7 day follow up email_Lab IC Document
Attchment I _20 day follow up email_Epi.docx Attchment I _20 day follow up email_Epi IC Document
Attachment N 20 day follow up email_Lab.docx Attachment N 20 day follow up email_Lab IC Document
Campy_SupportingStatement_B 12 20 13.docx Supporting Statement Part B IC Document
Campy_SupportingStatement_A 12 20 13.docx Supporting Statement Part A IC Document
ATTACHMENT C - Advance Notification Email docx.docx TB Advance Notice Emai; IC Document
ATTACHMENT D - Email with Instructions to Participate docx.docx TB Instructions IC Document
ATTACHMENT E - 1st Reminder Email (Day 10) docx.docx TB 1st Reminder IC Document
ATTACHMENT F - 2nd Reminder Email (Day 17) docx.docx TB 2nd Reminder IC Document
ATTACHMENT A- Data Collection Instrument_Word Version docx.docx TB Instrument - Word IC Document
Supporting Statement_B docx.docx TB SS Part B IC Document
Supporting Statement_A docx.docx TB SS Part A IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SHD Reporting (14EU) and Testing Practices and TB Elimination FOA (14GS)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Survey for Epidemiologist	Attachment F Campy Data Collection Epi Instrument (online version) 12 13 13.docx	Yes	Yes	Fillable Fileable
Form	none	Survey for Microbiolgist	Attachment K Campy Data Collection Lab Instrument (online version) 12 13 13.docx	Yes	Yes	Fillable Fileable
Form	none	TB Instrument - Web	ATTACHMENT B- Data Collection Instrument_Online Version docx.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 230	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	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	230	0	0	0	0	0
Annual IC Time Burden (Hours)	58	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment A Winnable battles 12 12 13	Attachement A Winnable battles 12 12 13.pdf	12/19/2013
Attachment B NNDSS website 12 12 13	Attachment B NNDSS website 12 12 13.pdf	12/19/2013
Attachment C LEDS website 12 12 13	Attachment C LEDS website 12 12 13.pdf	12/19/2013
Attachment D FoodNet website 12 12 13	Attachment D FoodNet website 12 12 13.pdf	12/19/2013
Email - Epi	Attachment G Introductory Email_Epi.docx	12/19/2013
Email - Lab	Attachment L Introductory Email_Lab.docx	12/19/2013
Attachment H 7 day follow up email_Epi	Attchment H 7 day follow up email_Epi.docx	12/19/2013
Attachment M 7 day follow up email_Lab	Attachment M 7 day follow up email_Lab.docx	12/19/2013
Attchment I _20 day follow up email_Epi	Attchment I _20 day follow up email_Epi.docx	12/19/2013
Attachment N 20 day follow up email_Lab	Attachment N 20 day follow up email_Lab.docx	12/19/2013
Supporting Statement Part B	Campy_SupportingStatement_B 12 20 13.docx	12/20/2013
Supporting Statement Part A	Campy_SupportingStatement_A 12 20 13.docx	12/20/2013
TB Advance Notice Emai;	ATTACHMENT C - Advance Notification Email docx.docx	01/21/2014
TB Instructions	ATTACHMENT D - Email with Instructions to Participate docx.docx	01/21/2014
TB 1st Reminder	ATTACHMENT E - 1st Reminder Email (Day 10) docx.docx	01/21/2014
TB 2nd Reminder	ATTACHMENT F - 2nd Reminder Email (Day 17) docx.docx	01/21/2014
TB Instrument - Word	ATTACHMENT A- Data Collection Instrument_Word Version docx.docx	01/21/2014
TB SS Part B	Supporting Statement_B docx.docx	01/22/2014
TB SS Part A	Supporting Statement_A docx.docx	01/22/2014

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

SHD Reporting (14EU) and Testing Practices and TB Elimination FOA (14GS)

Surveys of State, Tribal, Local and Territorial (STLT) Governmental Health Agencies

OMB: 0920-0879

IC ID: 210158

View Information Collection (IC)