OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

2014005XXX_DiarrhealDisease_AS

IC 211705 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⚠️ Notice: This information collection may be referencing outdated material.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
2014005XXX_DiarrhealDisease_AS	Form
Medical Abstraction Form Attachment 1-Medical Chart Abstraction Form.docx	Form
Case Questionnaire Attachment 2-Case questionnaire.doc	Form
American Samoa Epi-Aid Request 5-23-14.pdf Letter of Invitation	IC Document
2014005XXX_DiarrhealDisease_AS.docx Request for Approval	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

2014005XXX_DiarrhealDisease_AS

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	Medical Abstraction Form	Attachment 1-Medical Chart Abstraction Form.docx		No		Paper Only
Form	none	Case Questionnaire	Attachment 2-Case questionnaire.doc		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 Investigations Case Records System Notice

FR Citation: 51 FR 42466

Number of Respondents: 400

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	400	0	400	0	0	0
Annual IC Time Burden (Hours)	117	0	117	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
Letter of Invitation	American Samoa Epi-Aid Request 5-23-14.pdf	05/23/2014
Request for Approval	2014005XXX_DiarrhealDisease_AS.docx	05/23/2014

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