Information Collection

Human Infection with Novel Influenza A Virus Case Report Form

IC 199043 under ICR 201304-0920-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Human Infection with Novel Influenza A Virus Case Report Form Form
Human Infection with Novel Influenza A Virus Case Report Human Infection with Novel Influenza A Virus Case Report Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Human Infection with Novel Influenza A Virus Case Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	None	Human Infection with Novel Influenza A Virus Case Report Form	Human Infection with Novel Influenza A Virus Case Report Form.pdf		Yes	Yes	Fillable Fileable

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: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	57	57
Annual IC Time Burden (Hours)	29	29
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.