National Disease Surveillance Program - II. Disease Summaries

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Influenza Annual Survey	Form	Modified	Available
Antiviral-Resistant Influenza infection Case Report Form	Form and Instruction	New	Available
CMRS Weekly	Form	Modified	Available
CMRS Daily	Form	Modified	Available
Influenza-like illness Reporting	Form	Modified	Available
Influenza-like Illness Daily and year round	Form	Modified	Available
Form 55.20 Weekly Influenza Like Illness	Form	Modified	Available
Form 55.20 Weekly Influenza-like Illness	Form	Modified	Available
Pediatric Death Case Report	Form	Modified	Available
WHO Electronic Form	Form	Modified	Available
WHO Electronic	Form	Modified	Available
WHO Fax Form	Form	Modified	Available
Form Influenza Fax WHO Fax Form	Form	Modified	Available
Aggregate Hospital	Form	Modified	Available
Possible Human Rabies	Form	Modified	Available
Human Infection with Novel Influenza A Virus Case Report Form	Form	Modified	Available
Trace Forward	Form	Modified	Available
Influenza A Trace Back	Form	Modified	Available
Influenza A Case Investigation	Form	Modified	Available
Daily Case Status	Form	Modified	Available
Brucellosis Case Report Form	Form	Modified	Available
Babesiosis Case Report Form	Form and Instruction	Modified	Available
Form No Number HABISS Report	Form	Modified	Available
Form No number HABISS	Form	Modified	Available
Form CDC 52.12 National Outbreak Reporting System: Waterborne Disease Transmission	Form and Instruction	Modified	Available
Form 55.28 Lab confirmed cases of rabies	Form	Modified	Available
Form CDC 52.13 National Outbreak Reporting System	Form and Instruction	Modified	Available
Arboviral Diseases	Form and Instruction	Modified	Available
Form 1 Diarrheal Disease Surveillance Campylobacter	Form	Modified	Available
Change Request OMB 0920-0004 4-5-13.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2013-04-25	Repair queued
PHIN cover sheet.docx	Supplementary Document	Uploaded 2010-11-02	Available
PHLIP cover sheet.docx	Supplementary Document	Uploaded 2010-11-02	Available
Enhanced Animal Rabies Surveillance cover sheet.docx	Supplementary Document	Uploaded 2010-10-29	Available
NORS Form.pdf	Supplementary Document	Uploaded 2008-12-22	Available
FoodborneOutbreak Form 5213 ReportingInstructions.pdf	Supplementary Document	Uploaded 2007-01-17	Available
NREVSS PCR Worksheet CDC 55.83D.pdf	Supplementary Document	Uploaded 2007-01-17	Repair queued
NREVSS VI Worksheet CDC 55.83B.pdf	Supplementary Document	Uploaded 2007-01-17	Available
NREVSS EM Worksheet CDC 55.83C.pdf	Supplementary Document	Uploaded 2007-01-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
37707	0920-0004 Influenza Annual Survey 55.31A	Form	Modified	Influenza Annual Survey
206690	Antiviral-Resistant Influenza infection Case Report Form	Form and Instruction	New	Antiviral-Resistant Influenza infection Case Report Form
199058	CMRS Weekly - City Health Officer or Vital Statistics Registrars	Form	Modified	CMRS Weekly
199057	CMRS Daily - City Health Officer or Vital Statistics Registrars	Form	Modified	CMRS Daily
199056	Daily Influenza-like Illness year round	Form	Modified	Influenza-like illness Reporting
199055	Daily Influenza-like Illness Oct - May	Form	Modified	Influenza-like Illness Daily and year round
199054	Weekly Influenza-like Illiness year round 55.20	Form	Modified	Weekly Influenza Like Illness
199053	Weekly Influenza-like Illness Oct - May 55.20	Form	Modified	Weekly Influenza-like Illness
199052	Influenza Virus Electronic year round PHIN-MS	Other-Variables for Reporting	Modified
199051	Influenza Virus Electronic year round - PHLIP	Other-Variables for electronic reporting	Modified
199050	Influenza Associated Pediatric Death Case Report Form	Form	Modified	Pediatric Death Case Report
199049	Influenza virus Internet Year-Round 55.31	Form	Modified	WHO Electronic Form
199048	Influenza virus Internet Oct - May 55.31	Form	Modified	WHO Electronic
199047	Influenza virus fax year-round 55.31	Form	Modified	WHO Fax Form
199046	Influenza Virus Fax Oct-May 55.31	Form	Modified	WHO Fax Form
199045	Aggregate Hospitalization and Death Reporting Weekly	Form	Modified	Aggregate Hospital
199044	Possible Human Rabies - Patient Information Form	Form	Modified	Possible Human Rabies
199043	Human Infection with Novel Influenza A Virus Case Report Form	Form	Modified	Human Infection with Novel Influenza A Virus Case Report Form
199042	Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form	Form	Modified	Trace Forward
199041	Novel and Pandemic Influenza A Virus Infection Contact Trace Back Form	Form	Modified	Influenza A Trace Back
199040	Novel and Pandemic Influenza A Virus Infection Case Investigation Form	Form	Modified	Influenza A Case Investigation
199039	Daily Novel and Pandemic Influenza Virus State Case Status Summary Update	Form	Modified	Daily Case Status
199038	Brucellosis Case Report Form	Form	Modified	Brucellosis Case Report Form
199037	Babesiosis Case Report Form	Form and Instruction	Modified	Babesiosis Case Report Form
186749	HABISS Monthly Reporting Form	Form	Modified	HABISS Report
186748	HABISS	Form	Modified	HABISS
178375	0920-0004 Listeria Case Form	Instruction	Modified
178374	0920-0004 Suspected Viral Gastroenteritis (AKA Calicivirus Surveillance)	Instruction	Modified
178373	0920-0004 Cholera and Other Vibrio Illnesses 52.79	Instruction	Modified
178372	0920-0004 Waterborne Diseases Outbreak 52.12	Form and Instruction	Modified	National Outbreak Reporting System: Waterborne Disease Transmission
178371	Enhanced Animal Rabies Surveillance Monthly Report	Form	Modified	Lab confirmed cases of rabies
178370	Rabies Monthly Report (paper) 55.28	Instruction	Modified
178369	0920-0004 Foodborne Outbreak 52.13	Form and Instruction	Modified	National Outbreak Reporting System
178365	0920-0004 National Respiratory and Enteric Virus Surveillance System NREVSS 55.83A-D	Instruction	Modified
178364	0920-0004 National Enterovirus Surveillance Report 55.9	Instruction	Modified
178363	0920-0004 Arboviral Diseases	Form and Instruction	Modified	Arboviral Diseases
178362	0920-0004 Diarrheal Diseases Shigella	Instruction	Modified
178361	0920-0004 Diarrheal Diseases Salmonella	Instruction	Modified
178360	0920-0004 Diarrheal Diseases Campylobacter	Form	Modified	Diarrheal Disease Surveillance Campylobacter

ICR Details

OMB Control No: 0920-0004	ICR Reference No: 201304-0920-017
Status: Historical Active	Previous ICR Reference No: 201108-0920-011
Agency/Subagency: HHS/CDC	Agency Tracking No: 19323
Title: National Disease Surveillance Program - II. Disease Summaries
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/29/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/25/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	08/31/2014	08/31/2014
Responses	292,656	0	292,485
Time Burden (Hours)	56,222	0	56,136
Cost Burden (Dollars)	0	0	0

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Abstract: This is a change request. Data on disease and preventable conditions are collected in accordance with jointly approved plans by the Center for Disease Control and Prevention and the Council of State and Territorial Health Epidemiologists. This change request involves a new disease form to be added and some edits to existing forms.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 39

table that charts list of burden

IC Title	Form No.	Form Name
0920-0004 Arboviral Diseases	none	Arboviral Diseases
0920-0004 Cholera and Other Vibrio Illnesses 52.79
0920-0004 Diarrheal Diseases Campylobacter	1	Diarrheal Disease Surveillance Campylobacter
0920-0004 Diarrheal Diseases Salmonella
0920-0004 Diarrheal Diseases Shigella
0920-0004 Foodborne Outbreak 52.13	CDC 52.13	National Outbreak Reporting System
0920-0004 Influenza Annual Survey 55.31A	none	Influenza Annual Survey
0920-0004 Listeria Case Form
0920-0004 National Enterovirus Surveillance Report 55.9
0920-0004 National Respiratory and Enteric Virus Surveillance System NREVSS 55.83A-D
0920-0004 Suspected Viral Gastroenteritis (AKA Calicivirus Surveillance)
0920-0004 Waterborne Diseases Outbreak 52.12	CDC 52.12	National Outbreak Reporting System: Waterborne Disease Transmission
Aggregate Hospitalization and Death Reporting Weekly	none	Aggregate Hospital
Antiviral-Resistant Influenza infection Case Report Form	none	Antiviral-Resistant Influenza infection Case Report Form
Babesiosis Case Report Form	none	Babesiosis Case Report Form
Brucellosis Case Report Form	none	Brucellosis Case Report Form
CMRS Daily - City Health Officer or Vital Statistics Registrars	none	CMRS Daily
CMRS Weekly - City Health Officer or Vital Statistics Registrars	none	CMRS Weekly
Daily Influenza-like Illness Oct - May	none	Influenza-like Illness Daily and year round
Daily Influenza-like Illness year round	none	Influenza-like illness Reporting
Daily Novel and Pandemic Influenza Virus State Case Status Summary Update	none	Daily Case Status
Enhanced Animal Rabies Surveillance Monthly Report	55.28	Lab confirmed cases of rabies
HABISS	No number	HABISS
HABISS Monthly Reporting Form	No Number	HABISS Report
Human Infection with Novel Influenza A Virus Case Report Form	none	Human Infection with Novel Influenza A Virus Case Report Form
Influenza Associated Pediatric Death Case Report Form	none	Pediatric Death Case Report
Influenza Virus Electronic year round - PHLIP
Influenza Virus Electronic year round PHIN-MS
Influenza Virus Fax Oct-May 55.31	Influenza Fax	WHO Fax Form
Influenza virus Internet Oct - May 55.31	none	WHO Electronic
Influenza virus Internet Year-Round 55.31	none	WHO Electronic Form
Influenza virus fax year-round 55.31	none	WHO Fax Form
Novel and Pandemic Influenza A Virus Infection Case Investigation Form	none	Influenza A Case Investigation
Novel and Pandemic Influenza A Virus Infection Contact Trace Back Form	none	Influenza A Trace Back
Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form	none	Trace Forward
Possible Human Rabies - Patient Information Form	none	Possible Human Rabies
Rabies Monthly Report (paper) 55.28
Weekly Influenza-like Illiness year round 55.20	55.20	Weekly Influenza Like Illness
Weekly Influenza-like Illness Oct - May 55.20	55.20	Weekly Influenza-like Illness

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	292,656	292,485	0	171	0	0
Annual Time Burden (Hours)	56,222	56,136	0	86	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This change request entails a new disease form being added and a few edits to existing forms. The existing form Novel Human Influenza A Virus Infection Case Report Form title will change to Human Infection with Novel Influenza A Virus Case Report Form. The new form Antiviral-Resistant Influenza Infection Case Report Form will add 86 burden hours. See change justification for other nonmaterial/nonsubstantial changes.

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Annual Cost to Federal Government: $40,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/25/2013

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