OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

2014004XXX_Legionnaires' Disease_Alabama 2014

IC 211702 under ICR 201311-0920-016 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2014004XXX_Legionnaires' Disease_Alabama 2014	Form
Record Abstraction Appendix 1. Medical Record Abstraction Form.doc	Form
Interview Questionnaire Appendix 2. Interview Questionnaire.docx	Form
REQUEST for EPI-AID UAB Legionella Outbreak.msg Email Invitation requesting Support	IC Document
2014003XXX_LegionnairesDisease_AL.docx Request for Approval	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

2014004XXX_Legionnaires' Disease_Alabama 2014

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR USC 301 [241] (To search for a specific CFR, visit the Code of Federal Regulations.)

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
Form	none	Record Abstraction	Appendix 1. Medical Record Abstraction Form.doc		No		Paper Only
Form	none	Interview Questionnaire	Appendix 2. Interview Questionnaire.docx		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0113 Epidemic Investigation Case Records System Notice

FR Citation: 51 FR 42466

Number of Respondents: 45

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 New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	45	0	45	0	0	0
Annual IC Time Burden (Hours)	11	0	11	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Email Invitation requesting Support	REQUEST for EPI-AID UAB Legionella Outbreak.msg	05/23/2014
Request for Approval	2014003XXX_LegionnairesDisease_AL.docx	05/23/2014

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