National Disease Surveillance Program - II. Disease Summaries

Forms and Documents

Document Name	Status
Form CDC 55.31A Att F US WHO Colloborating Laboratories Influenza Testing Methods Assessment Form	Modified
Att X Middle East Respiratory Syndrome Coronavirus (MERS) Patient Under Investigation (PUI) Form Form	New
Att W Adenovirus Typing Report Form Form	New
Att T Antiviral Resistant Influenza Infection Case Report Form Form	New
Att M Human Infections with Novel Influenza A Virus Severe Outcomes Form	New
Att L Human Infection with Novel Influenza A Virus with Suspected Avian Source Form	New
Form CDC 43.5 Att R_CMRS - City Health Officer or Vital Statistics Registrars Weekly Mortality Report Form	Modified
Form CDC 43.50 Att Q_122 CMRS - City Health Officer or Vital Statistics Registrars Daily Mortality Report Form	Modified
Form CDC 55.20 Att G US Outpatient Influenza-like Illness Surveillance Network (ILINet) Weekly Form	Modified
Daily Influenza-like Illness Oct - May Form	Removed
Att I_ US Outpatient Influenza-like Illiness Surveillance Network (ILINet) Daily Reports Form	Modified
Form 55.20 Weekly Influenza-like Illness Oct - May 55.20 Form	Removed
Att J_Influenza Associated Pediatric Mortality Case Report Form Form	Modified
Form CDC 55.31 Att E_WHO Collaborating Center for Influenza Virus Surveillance Internet Year Round Form	Modified
Influenza virus Internet Oct - May 55.31 Form	Removed
Influenza virus fax year-round 55.31 Form	Removed
Form Influenza Fax Influenza Virus Fax Oct-May 55.31 Form	Removed
Att S_Aggregate Hospitalization and Death Reporting Activity Weekly Report Form Form	Modified
Att K Human Infection with Novel Influenza A Virus Case Report Form Form	Modified
Att N Novel Influenza A Virus Infection Contact Tracing Form Form	Modified
Novel and Pandemic Influenza A Virus Infection Contact Trace Back Form Form	Removed
Att P Novel Influenza A Virus Case Screening Form Form	Modified
Att O_Novel Influenza A Virus Status Case Status Summary Form	Modified
Form No Number HABISS Monthly Reporting Form Form	Removed
Form No number HABISS Form	Removed
Att Y_ Form for Submitting Specimens from Suspected Norovirus Outbreak Form	Modified
Form CDC 52.12 Att Z_ Waterborne Diseases Transmission Form and Instruction	Modified
Form CDC 52.13 Att D_Foodborne Disease Transmission Person-to-Person_Animal Contact Form and Instruction	Modified
Form CDC 55.83 Att U_National Respiratory and Enteric Virus Surveillance System (NREVSS) Laboratory Assessment Form	Modified
Form CDC 55.90 Att V_ National Enterovirus Surveillance Report 55.9 Form	Modified
Att G_US Outpatient ILI Surv Network (ILINet) Weekly CDC 55.20.pdf Supplementary Document	2014-08-18
SupSta A_0920-0004_REVISION.doc Supporting Statement A	2014-07-25
Att C_60d FRN (0920-0004).pdf Supplementary Document	2014-07-25
Att B_Disease Summaries.doc Supplementary Document	2014-07-25
Att A_Authorizing Legislation.pdf Supplementary Document	2014-07-25
SupSta B_0920-0004_REVISION.docx Supporting Statement B	2014-07-25

IC Document Collections

IC ID	Document Title	Status
37707	Att F US WHO Colloborating Laboratories Influenza Testing Methods Assessment Form	Modified
212473	Att X Middle East Respiratory Syndrome Coronavirus (MERS) Patient Under Investigation (PUI) Form Form	New
212472	Att W Adenovirus Typing Report Form Form	New
212471	Att T Antiviral Resistant Influenza Infection Case Report Form Form	New
212470	Att M Human Infections with Novel Influenza A Virus Severe Outcomes Form	New
212469	Att L Human Infection with Novel Influenza A Virus with Suspected Avian Source Form	New
199058	Att R_CMRS - City Health Officer or Vital Statistics Registrars Weekly Mortality Report Form	Modified
199057	Att Q_122 CMRS - City Health Officer or Vital Statistics Registrars Daily Mortality Report Form	Modified
199056	Att G US Outpatient Influenza-like Illness Surveillance Network (ILINet) Weekly Form	Modified
199055	Daily Influenza-like Illness Oct - May Form	Removed
199054	Att I_ US Outpatient Influenza-like Illiness Surveillance Network (ILINet) Daily Reports Form	Modified
199053	Weekly Influenza-like Illness Oct - May 55.20 Form	Removed
199052	Att BB_ Influenza Virus Electronic year round PHIN-MS Other-Variables for Reporting	Modified
199051	Att AA_ Influenza Virus Electronic year round - PHLIP_HL7 Messaging Data Elements Other-Variables for Electronic Reporting	Modified
199050	Att J_Influenza Associated Pediatric Mortality Case Report Form Form	Modified
199049	Att E_WHO Collaborating Center for Influenza Virus Surveillance Internet Year Round Form	Modified
199048	Influenza virus Internet Oct - May 55.31 Form	Removed
199047	Influenza virus fax year-round 55.31 Form	Removed
199046	Influenza Virus Fax Oct-May 55.31 Form	Removed
199045	Att S_Aggregate Hospitalization and Death Reporting Activity Weekly Report Form Form	Modified
199043	Att K Human Infection with Novel Influenza A Virus Case Report Form Form	Modified
199042	Att N Novel Influenza A Virus Infection Contact Tracing Form Form	Modified
199041	Novel and Pandemic Influenza A Virus Infection Contact Trace Back Form Form	Removed
199040	Att P Novel Influenza A Virus Case Screening Form Form	Modified
199039	Att O_Novel Influenza A Virus Status Case Status Summary Form	Modified
186749	HABISS Monthly Reporting Form Form	Removed
186748	HABISS Form	Removed
178374	Att Y_ Form for Submitting Specimens from Suspected Norovirus Outbreak Form	Modified
178372	Att Z_ Waterborne Diseases Transmission Form and Instruction	Modified
178369	Att D_Foodborne Disease Transmission Person-to-Person_Animal Contact Form and Instruction	Modified
178365	Att U_National Respiratory and Enteric Virus Surveillance System (NREVSS) Laboratory Assessment Form	Modified
178364	Att V_ National Enterovirus Surveillance Report 55.9 Form	Modified

ICR Details

OMB Control No: 0920-0004	ICR Reference No: 201407-0920-012
Status: Historical Active	Previous ICR Reference No: 201402-0920-007
Agency/Subagency: HHS/CDC	Agency Tracking No: 21418
Title: National Disease Surveillance Program - II. Disease Summaries
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/29/2014
	Date Received in OIRA: 08/25/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2017	36 Months From Approved	10/31/2014
Responses	175,180	0	199,167
Time Burden (Hours)	31,921	0	48,493
Cost Burden (Dollars)	0	0	0

---

Abstract: The Centers for Disease Control and Prevention (CDC) requests a three year approval for the Revision of National Disease Surveillance Program - II. Disease Summaries, OMB Control Number 0920-0004. Expiration Date August 31, 2014. Proposed revisions include shifting information collection management responsibilities to the National Center for Immunization and Respiratory Diseases (NCIRD) and consolidating various forms to reflect more current technology trends. CDC also requests the use of 2 new Influenza forms to enhance surveillance and assist in understanding the complexities of these newer viruses: Human Infection with Novel Influenza A Virus Severe Outcomes; Human Infection with Novel Influenza A Virus with Suspected Avian Source. Due to the uncertainty regarding MERS-CoV and the potential threat to human health, CDC has developed a new form, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) [Patient Under Investigation] form. The Adenovirus Typing Report Form allows for a passive surveillance mechanism that collects adenovirus typing data to enhance adenovirus circulation data already collected by the National Respiratory and Enteric Virus Surveillance System (NREVSS). The Harmful Algal Bloom-related Illness forms are being discontinued. The methodology for reporting varies depending on the occurrence, modes of transmission, infectious agents, and epidemiologic measures. There is no cost to respondents other than their time.

---

Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 37	02/25/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 46828	08/11/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 24

IC Title	Form No.	Form Name
Daily Influenza-like Illness Oct - May	none	Influenza-like Illness Daily and year round
Att F US WHO Colloborating Laboratories Influenza Testing Methods Assessment	CDC 55.31A	US WHO Collaborating Laboratories Flu Testing Methods Assessment
Att V_ National Enterovirus Surveillance Report 55.9	CDC 55.90	Enterovirus Surveillance System Report Form
Att U_National Respiratory and Enteric Virus Surveillance System (NREVSS) Laboratory Assessment	CDC 55.83A, CDC 55.83D, CDC 55.83, CDC 55.83B	National Respiratory and Enteric Virus Surveillance System (NREVSS) Laboratory Assessment ,   NREVSS Antigen Detection Worksheet ,   NREVSS Polymerase Chain Reaction (PCR) Worksheet ,   NREVSS Virus Isolation (culture) Worksheet
Att D_Foodborne Disease Transmission Person-to-Person_Animal Contact	CDC 52.13	National Outbreak Reporting System
Att Z_ Waterborne Diseases Transmission	CDC 52.12	National Outbreak Reporting System: Waterborne Disease Transmission
Att Y_ Form for Submitting Specimens from Suspected Norovirus Outbreak	None	Form for Submitting Specimens from Suspected Norovirus Outbreaks
HABISS Monthly Reporting Form	No Number	HABISS Report
Att O_Novel Influenza A Virus Status Case Status Summary	None	Novel Influenza A Virus Case Status Summary
Att P Novel Influenza A Virus Case Screening Form	None	Novel Influenza A Virus Case Screening Form
Influenza virus fax year-round 55.31	none	WHO Fax Form
HABISS	No number	HABISS
Att K Human Infection with Novel Influenza A Virus Case Report Form	none, None	Human Infection with Novel Influenza A Virus Case Report Form ,   Human Infection with Novel Influenza A Virus Case Report Form
Att S_Aggregate Hospitalization and Death Reporting Activity Weekly Report Form	none	Aggregate Hospital
Influenza virus Internet Oct - May 55.31	none	WHO Electronic
Att E_WHO Collaborating Center for Influenza Virus Surveillance Internet Year Round	CDC 55.31	WHO Collaborating Center for Influenza Virus Surveillance (Internet: Year Round)
Att AA_ Influenza Virus Electronic year round - PHLIP_HL7 Messaging Data Elements
Att BB_ Influenza Virus Electronic year round PHIN-MS
Att I_ US Outpatient Influenza-like Illiness Surveillance Network (ILINet) Daily Reports	None	US Outpatient Influenza like Illness Surveillance Network (ILINet) Daily Reports
Att G US Outpatient Influenza-like Illness Surveillance Network (ILINet) Weekly	CDC 55.20	US Outpatient Influenza-like Illness Surveillance Network (ILINet) Weekly
Att Q_122 CMRS - City Health Officer or Vital Statistics Registrars Daily Mortality Report	CDC 43.50	122 CMRS -City Health Officers or Vital Statistics Registrars Daily Mortality Report
Att R_CMRS - City Health Officer or Vital Statistics Registrars Weekly Mortality Report	CDC 43.5, none	122 CMRS-City Health Officers or Vital Statistics Registrars Weekly Mortality Report ,   CMRS Weekly
Att L Human Infection with Novel Influenza A Virus with Suspected Avian Source	None	Human Infection with Novel Influenza A Virus with Suspected Avian Source
Att M Human Infections with Novel Influenza A Virus Severe Outcomes	None	Human Infection with Novel Influenza A Virus Severe Outcomes
Att T Antiviral Resistant Influenza Infection Case Report Form	None	Antiviral Resistant Influenza Infection Case Report Form
Att W Adenovirus Typing Report Form	None	Adenovirus Typing Report Form
Att X Middle East Respiratory Syndrome Coronavirus (MERS) Patient Under Investigation (PUI) Form	None	Middle East Respiratory Syndrome Coronavirus (MERS) Patient Under Investigation (PUI) Form
Weekly Influenza-like Illness Oct - May 55.20	55.20	Weekly Influenza-like Illness
Novel and Pandemic Influenza A Virus Infection Contact Trace Back Form	none	Influenza A Trace Back
Att N Novel Influenza A Virus Infection Contact Tracing Form	None	Novel Influenza A Virus Infection Contact Tracing Form
Influenza Virus Fax Oct-May 55.31	Influenza Fax	WHO Fax Form
Att J_Influenza Associated Pediatric Mortality Case Report Form	None	Influenza Associated Pediatric Mortality Case Report Form

---

ICR Summary 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	175,180	199,167	0	-4,514	-19,473	0
Annual Time Burden (Hours)	31,921	48,493	0	-10,841	-5,731	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Forms

Short Statement: This is a request for a revision. Proposed revisions include shifting information collection management responsibilities to the National Center for Immunization and Respiratory Diseases (NCIRD) and consolidating various forms to reflect more current technology trends.

---

Annual Cost to Federal Government: $51,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/25/2014

---