National Disease Surveillance Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form none assigned Tularemia	Form	Modified	Available
Form none assigned Trichinosis Surveillance Case Report	Form	Modified	Available
Form none assigned Tick-borne Rickettsial Disease Case Report	Form	Modified	Available
Form none assigned Reye Syndrome Case Surveillance Report	Form	Modified	Available
Form none assigned Q Fever	Form	Modified	Available
Form none assigned Plaque Case Investigation Report	Form	Modified	Available
Form CDC 54.1 Malaria Case Surveillance Report	Form	Modified	Repair queued
Form none assigned Lyme Disease Report	Form	Modified	Available
Form CDC 52.56 Legionellosis Case Report	Form	Modified	Repair queued
Form none assigned Kawasaki Syndrome	Form	Modified	Repair queued
Form none assigned Hantavirus Pulmonary Syndrome	Form	Modified	Repair queued
Form none assigned Dengue Case Investigation	Form	Modified	Repair queued
Form none assigned Cyclosporiasis	Form	Modified	Available
Form none assigned CJD	Form	Modified	Repair queued
Form No number Viral Hepatitis Case Record	Form	Modified	Available
Form No number Typhoid Fever Surveillance Report	Form	Modified	Repair queued
Leptospirosis Case Report	Form	New	Available
OMB 0920-0009 change request for Lepto_21May13.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2013-05-22	Available
CDCMalaria54 1_changesAppenA2009.xls	Supplementary Document	Uploaded 2010-02-25	Available
Currentmalaria_form.pdf	Supplementary Document	Uploaded 2010-02-25	Repair queued
DCIF_English_Color_proposed_jun2009.ppt	Supplementary Document	Uploaded 2009-06-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
46212	Tularemia	Form	Modified
46211	Trichinosis Surveillance Case Report	Form	Modified
46210	Tick-borne Rickettsial Disease Case Report	Form	Modified
46209	Reye Syndrome Case Surveillance Report	Form	Modified
46208	Q Fever	Form	Modified
46207	Plaque Case Investigation Report	Form	Modified
46206	Malaria Case Surveillance Report	Form	Modified
46205	Lyme Disease Report	Form	Modified
46204	Legionellosis Case Report	Form	Modified
46203	Kawasaki Syndrome	Form	Modified
46202	Hantavirus Pulmonary Syndrome	Form	Modified
46201	Dengue Case Investigation	Form	Modified
46200	Cyclosporiasis	Form	Modified
46199	CJD	Form	Modified
46198	Viral Hepatitis Case Record	Form	Modified
37710	Typhoid Fever Surveillance Report	Form	Modified
207080	Leptospirosis Case Report	Form	New

ICR Details

OMB Control No: 0920-0009	ICR Reference No: 201305-0920-010
Status: Historical Active	Previous ICR Reference No: 201303-0920-007
Agency/Subagency: HHS/CDC	Agency Tracking No: 19662
Title: National Disease Surveillance Program
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: 05/30/2013
	Date Received in OIRA: 05/28/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2016	04/30/2016	04/30/2016
Responses	45,259	0	45,145
Time Burden (Hours)	11,476	0	11,447
Cost Burden (Dollars)	0	0	0

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Abstract: CDC requests the addition of the leptospirosis case report form as CSTE approved the reinstatement of leptospirosis as a notifiable condition.

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Authorizing Statute(s): US Code: 42 USC 306 Name of Law: National Center for Health Statistics
   US Code: 42 USC 301 Name of Law: General Powers and Duties of Public Health Service
  

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? Yes

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Number of Information Collection (IC) in this ICR: 17

table that charts list of burden

IC Title	Form No.	Form Name
Typhoid Fever Surveillance Report	No number	Typhoid Fever Surveillance
Viral Hepatitis Case Record	No number	Hepatitis Case Record
CJD	none assigned	CJD
Cyclosporiasis	none assigned	Cyclosporiasis
Dengue Case Investigation	none assigned, none assigned	Dengue ,   Dengue-Spanish
Hantavirus Pulmonary Syndrome	none assigned	Hantavirus
Kawasaki Syndrome	none assigned	Kawasaki
Legionellosis Case Report	CDC 52.56	Legionellosis Case Report
Lyme Disease Report	none assigned	Lyme Disease
Malaria Case Surveillance Report	CDC 54.1	Malaria Case Surveillance Report
Plaque Case Investigation Report	none assigned	Plague
Q Fever	none assigned	Q Fever
Reye Syndrome Case Surveillance Report	none assigned	Reye Syndrome
Trichinosis Surveillance Case Report	none assigned	Trichinosis
Tularemia	none assigned	Tularemia
Tick-borne Rickettsial Disease Case Report	none assigned	Tick-Borne
Leptospirosis Case Report	none	Leptospirosis Case Report

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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	45,259	45,145	0	114	0	0
Annual Time Burden (Hours)	11,476	11,447	0	29	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: The reinstatement addition of leptospirosis as a notifiable condition as recommended by CSTE adds 29 burden hours to this collection.

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Annual Cost to Federal Government: $80,000

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: 05/28/2013

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