Information Collection Request

Emergency Epidemic Investigation Data Collections - Expedited Reviews

ICR 201311-0920-016 · OMB 0920-1011 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Focus Group Guide Form New Repair queued
Interview Guide Form New Available
Consent Form New Available
Case Investigation Form New Repair queued
KAP Survey Form New Repair queued
Appendix 1 - Ebola Case Investigation Form Form New Available
Appendix 2 - Ebola Case Contact Questionnaire Form and Instruction New Available
Focus Group Guide Form and Instruction New Available
Field Guide Form and Instruction New Available
Observation Guide Form and Instruction New Available
Family Interview Questionnaire Form New Repair queued
Medical Chart Abstraction Form New Available
Reprocessing Observation Checklist Form New Available
Outpatient Dialysis Practices Survey Form New Repair queued
Chart Abstraction Form New Available
Family interview Form New Available
Chart Abstraction Form New Available
Contact Listing Form Form New Available
Case Report Form Form New Available
Form 0920-1011 Appendix 2- Contact Tracing Form Form New Available
Form 0920-1011 Appendix 1- Case Investigation Form Form and Instruction New Available
Case Report (Spanish) Form New Available
Case Report (English) Form New Available
Individual Questionnaire Form New Available
Household Questionnaire Form New Available
Form CDC 56.31 A REV. 0 Dengue Case Investigation Report Form and Instruction New Available
Case Questionnaire Form New Available
Medical Abstraction Form Form New Available
Interview Questionnaire Form New Repair queued
Record Abstraction Form New Available
Follow-up Questionnaire for Asymptomatic Passengers and Crew Form New Available
Questionnaire for Passengers and Crew Form New Available
EEI GenICR_Sup St B_3_20_14.docx Supporting Statement B Uploaded 2014-03-25 Available
EEI GenICR 0920-13ZJ_App 6_Online Survey Case Finding Questionnaire_11-06-2013.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_App 5_Phone Interview Questionnaire Patient_11-06-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_App 4_Q Fever Person Interview Questionnaire_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_App 3 _Hantav Pulm Synd Questionnaire_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_App 2_GBS Case Questionnaire_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_App 1_Chart Abstract Form_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_Attach H_Biospecimen Storage Consent_11-06-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR_0920-13ZJ_Attach G _Emer Epi Invest_IRB Letter_11-06-2013_Subm.pdf Supplementary Document Uploaded 2013-11-20 Available
EEI Gen ICR 0920-13ZJ_Attach F_Epi Invest SORN_11-06-2013.doc Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_Attach E _Burden Memo_3-20-14.docx Supplementary Document Uploaded 2014-03-25 Available
EEI_Attach D_Request for Approval_3_20_14.docx Supplementary Document Uploaded 2014-03-25 Available
EEI GenICR 0920-13ZJ_Attach C_ Steps Conduct Emer Epi Invest_3_20_14.docx Supplementary Document Uploaded 2014-03-25 Available
EEI GenICR_0920-13ZJ_Attach B _Emer Epi Invest_Pub 60-day FRN_11-06-2013_Subm.pdf Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR_0920-13ZJ_Attach A_Auth Legis Emer Epi Invest_11-06-2013_Subm.pdf Supplementary Document Uploaded 2013-11-20 Repair queued
EEI_GenICR_Sup St A_3_20_14.docx Supporting Statement A Uploaded 2014-03-25 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
213737 Suicide _VA Form NewFocus Group Guide
213737 Suicide _VA Form NewInterview Guide
213373 CCRF_Georgia Form NewConsent
213373 CCRF_Georgia Form NewCase Investigation
213373 CCRF_Georgia Form NewKAP Survey
213323 Ebola_TX Form NewAppendix 1 - Ebola Case Investigation Form
213323 Ebola_TX Form and Instruction NewAppendix 2 - Ebola Case Contact Questionnaire
213274 Ebola_West Africa_2014 Form and Instruction NewFocus Group Guide
213274 Ebola_West Africa_2014 Form and Instruction NewField Guide
213274 Ebola_West Africa_2014 Form and Instruction NewObservation Guide
213233 Pseudomonas NICU_CA Other-WORD New
213189 Pediatric cluster of neurologic symptoms - Colorado Form NewFamily Interview Questionnaire
213189 Pediatric cluster of neurologic symptoms - Colorado Form NewMedical Chart Abstraction
213101 BSI_CA Form NewReprocessing Observation Checklist
213101 BSI_CA Form NewOutpatient Dialysis Practices Survey
213101 BSI_CA Form NewChart Abstraction
212908 2014016-XXX_Ebola_DRC Other-WORD New
212644 2014015-XXX_Parechovirus_Multi Form NewFamily interview
212644 2014015-XXX_Parechovirus_Multi Form NewChart Abstraction
212395 2014014-XXX Ebola_Sierra Leone Other-PDF New
212348 2014013-XXX_Resp Illness UAC_Multi Other-WORD New
212320 2014012-XXX Resp Illness UC_CA Other-WORD New
212266 2014011-XXX Ebola_Liberia Form NewContact Listing Form
212266 2014011-XXX Ebola_Liberia Form NewCase Report Form
212227 2014009-XXX_Chikungunya_US Service Org Volunteers New
212127 2014010-XXX Ebola_Guinea Form NewAppendix 2- Contact Tracing Form
212127 2014010-XXX Ebola_Guinea Form and Instruction NewAppendix 1- Case Investigation Form
211951 2014008-XXX Chikungunya_PR Form NewCase Report (Spanish)
211951 2014008-XXX Chikungunya_PR Form NewCase Report (English)
211951 2014008-XXX Chikungunya_PR Form NewIndividual Questionnaire
211951 2014008-XXX Chikungunya_PR Form NewHousehold Questionnaire
211894 Chikungunya_USVI Form and Instruction NewDengue Case Investigation Report
211894 Chikungunya_USVI Other-WORD New
211760 20140006XXX Measles FSM Other-WORD New
211705 2014005XXX_DiarrhealDisease_AS Form NewCase Questionnaire
211705 2014005XXX_DiarrhealDisease_AS Form NewMedical Abstraction Form
211702 2014004XXX_Legionnaires' Disease_Alabama 2014 Form NewInterview Questionnaire
211702 2014004XXX_Legionnaires' Disease_Alabama 2014 Form NewRecord Abstraction
211682 2014E003XXX_MERS-CoV_GA Form NewFollow-up Questionnaire for Asymptomatic Passengers and Crew
211682 2014E003XXX_MERS-CoV_GA Form NewQuestionnaire for Passengers and Crew

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
03/31/2017 36 Months From Approved
36,000 0 0
18,000 0 0
0 0 0





Reginfo record details
21
table that charts list of burden
IC Title Form No. Form Name
20140006XXX Measles FSM
2014004XXX_Legionnaires' Disease_Alabama 2014 none, none ,  
2014005XXX_DiarrhealDisease_AS none, none ,  
2014008-XXX Chikungunya_PR none, none, none, none ,   ,   ,  
2014009-XXX_Chikungunya_US Service Org Volunteers
2014010-XXX Ebola_Guinea 0920-1011, 0920-1011 ,  
2014011-XXX Ebola_Liberia none, none ,  
2014012-XXX Resp Illness UC_CA
2014013-XXX_Resp Illness UAC_Multi
2014014-XXX Ebola_Sierra Leone
2014015-XXX_Parechovirus_Multi none, none ,  
2014016-XXX_Ebola_DRC
2014E003XXX_MERS-CoV_GA none, none ,  
BSI_CA none, none, none ,   ,  
CCRF_Georgia none, none, none ,   ,  
Chikungunya_USVI CDC 56.31 A REV. 06/2006
Ebola_TX None, None ,  
Ebola_West Africa_2014 none, none, none ,   ,  
Pediatric cluster of neurologic symptoms - Colorado none, none ,  
Pseudomonas NICU_CA
Suicide _VA none, none ,  

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 36,000 0 0 36,000 0 0
Annual Time Burden (Hours) 18,000 0 0 18,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No