Information Collection

Post-Discharge Hospital Patients without MRSA infection (Control Patients) Telephone Interview

IC 205891 under ICR 201302-0920-016 · OMB 0920-0958.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment G - Telephone Interview Revised_4_01.04.2013_clean.docx	Instruction
Attachment C. ABCs MRSA. CRF.pdf Attachment C. ABCs MRSA. CRF	IC Document
Attachment D. MR review form for Case and Control.pdf Attachment D. MR review form for Case and Control	IC Document
Attachment H_ Nursing Home Medical Record review Form.pdf Attachment H_ Nursing Home Medical Record review Form	IC Document

IC Title:

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
Instruction			Attachment G - Telephone Interview Revised_4_01.04.2013_clean.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 190

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	190	190
Annual IC Time Burden (Hours)	63	63
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C. ABCs MRSA. CRF	Attachment C. ABCs MRSA. CRF.pdf	02/15/2013
Attachment D. MR review form for Case and Control	Attachment D. MR review form for Case and Control.pdf	02/15/2013
Attachment H_ Nursing Home Medical Record review Form	Attachment H_ Nursing Home Medical Record review Form.pdf	02/15/2013

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