Information Collection

Evaluating the Effectiveness of Ebola CARE Plus Program

IC 215939 under ICR 201203-0920-007 · OMB 0920-0932.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0932 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Evaluating the Effectiveness of Ebola CARE Plus Program	Form and Instruction
In-person survey of traveler intercepted at the airport Attachment A In person survey at airport_Responses to OMBcomments.clean.docx	Form and Instruction
Telephone survey within 3-5 days after airport survey Attachment B Telephone Survey within 3-5 days of airport survey AR 03 03 15.docx	Form and Instruction
Telephone Survey 2 Days before Last Scheduled Day To Rep Attachment C Telephone Survey 2 days before reporting end date AR 03 03 15.docx	Form and Instruction
Data Request to Health Departments Attachment D Data request to health departments _Response to OMBcomments.clean.docx	Form and Instruction
Cultural Sensitivity Assessment Tool Attachment E Cultural Competency Assessment Tool Responses to OMBcomments.clean.docx	Form and Instruction
Statement A 02APR2015_Responses to OMBcomments.clean.docx Supporting Statement A	IC Document
Statement B 02APR2015_Response to OMBcomments.clean.docx Supporting Statement B	IC Document
Attachment F Ebola CARE Kit.pdf Ebola CARE Kit - Review Material	IC Document
Attachment H.Letter of Determination.pdf Research Determination Letter	IC Document

IC Title:

Evaluating the Effectiveness of Ebola CARE Plus Program

Agency IC Tracking Number:

0920-0932

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 and Instruction	None	In-person survey of traveler intercepted at the airport	Attachment A In person survey at airport_Responses to OMBcomments.clean.docx	None	Yes	Yes	Fillable Fileable
Form and Instruction	None	Telephone survey within 3-5 days after airport survey	Attachment B Telephone Survey within 3-5 days of airport survey AR 03 03 15.docx	None	Yes	Yes	Fillable Fileable
Form and Instruction	None	Telephone Survey 2 Days before Last Scheduled Day To Report to Health Department	Attachment C Telephone Survey 2 days before reporting end date AR 03 03 15.docx	None	Yes	Yes	Fillable Fileable
Form and Instruction	None	Data Request to Health Departments	Attachment D Data request to health departments _Response to OMBcomments.clean.docx	None	Yes	Yes	Fillable Fileable
Form and Instruction	None	Cultural Sensitivity Assessment Tool	Attachment E Cultural Competency Assessment Tool Responses to OMBcomments.clean.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09200171 - Quarantine and Traveler Related Activities

FR Citation: 72 FR 70867

Number of Respondents: 3,008

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,008	3,008
Annual IC Time Burden (Hours)	1,239	1,239
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	Statement A 02APR2015_Responses to OMBcomments.clean.docx	04/02/2015
Supporting Statement B	Statement B 02APR2015_Response to OMBcomments.clean.docx	04/02/2015
Ebola CARE Kit - Review Material	Attachment F Ebola CARE Kit.pdf	04/02/2015
Research Determination Letter	Attachment H.Letter of Determination.pdf	04/02/2015

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