Screening Form

Clostridium difficile Infection (CDI) Surveillance

Documents and Forms

Document Name Document Type
Form New form Screening Form Form and Instruction
New form Attachment E Screening Questions for CDI Attachment E - Screening Questions for Clostridium difficile Telephone Interview.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Screening Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	New form	Attachment E Screening Questions for CDI	Attachment E - Screening Questions for Clostridium difficile Telephone Interview.doc		No	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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