OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

2014011-XXX Ebola_Liberia

IC 212266 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
2014011-XXX Ebola_Liberia Form
Case Report Form Appendix 1--CASE REPORT FORM.pdf Form
Contact Listing Form Appendix 2--CONTACT LISTING FORM.pdf Form
2014011-XXX_Ebola_Liberia Request.pdf Letter of Invitation IC Document
2014011-XXX_Ebola_Liberia.docx Request for Approval IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2014011-XXX Ebola_Liberia	Agency IC Tracking Number:	0920-14ANY

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Case Report Form	Appendix 1--CASE REPORT FORM.pdf		No		Paper Only
Form	none	Contact Listing Form	Appendix 2--CONTACT LISTING FORM.pdf		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemic Investigation Case Records HHS/CDC	FR Citation: 51 FR 42466

Number of Respondents: 2,600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	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	2,600	0	2,600	0	0	0
Annual IC Time Burden (Hours)	350	0	350	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Letter of Invitation	2014011-XXX_Ebola_Liberia Request.pdf	07/08/2014
Request for Approval	2014011-XXX_Ebola_Liberia.docx	07/08/2014

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