Information Collection

Formative Research Legionella

IC 223243 under ICR 201408-0920-009 · OMB 0920-0800.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0800 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 1 Treating Clinician_Screener.docx	Other-WORD
Attachment 2 Infection Control Clinician_Screener.docx	Other-WORD
Attachment 3 Building Managers and Water Maintenance Staff_Screener.docx	Other-WORD
Attachment 4 Water System Risk Managment and Remediation Staff_Screener.docx	Other-WORD
Attachment 9 Treating Clinician_Interview Guide.docx	Other-WORD
Attachment 10 Infection Control Clinician_Interview Guide.docx	Other-WORD
Attachment 11 Building Managers and Water Maintenance Staff_Interview Guide.docx	Other-WORD
Attachment 12 Water System Risk Management and Remediation Staff_Interview Guide.docx	Other-WORD
Attachment 5 Treating Clinician_Consent Form.doc Att 5_Treating Clinician Consent	IC Document
Attachment 6 Infection Control Clinician_Consent Form.doc Att 6_ Infection Control Clinician Consent	IC Document
Attachment 7 Building Managers and Water Maintenance Staff_Consent Form.doc Att 7_Building Mgr and Water Maint. Staff Consent	IC Document
Attachment 8 Water System Risk Management and Remediation Staff_Consent Form.doc Att 8_Water System Risk Mgmt & Remediation Staff Consent	IC Document
Attachment 13 Treating Clinician_Test Materials.pdf Att 13_Treating Clinician_Test materials	IC Document
Attachment 14 Infection Control Clinician_Test Materials.pdf Att 14_Infection Control Clinician_Test materials	IC Document
Attachment 15 Building Managers and Water Maintenance Staff_Test Materials.pdf Att 15_Bldg Mgrs and Water Maint. Staff_ Test materials	IC Document
Attachment 16 Water System Risk Management and Remediation Staff_Test Materials.pdf Att 16_Water Risk Mgmt and Remediation Staff_Test materials	IC Document
Attachment 17 Email Instructions_Interview Participation.docx Att 17_Email Instructions_Interview Participation	IC Document
Attachment 18 Remote Testing Procedures.docx Att 18_Remote Testing Procedures	IC Document
SS A 2016 Legionella_8 29 2016 final.docx Supporting Statement A	IC Document
SS B 2016 Legionella_8 29 2016 final.docx Supporting Statement B	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Formative Research Legionella

Agency IC Tracking Number:

16BCR

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD	Attachment 3 Building Managers and Water Maintenance Staff_Screener.docx	Yes	Yes	Fillable Printable
Other-WORD	Attachment 4 Water System Risk Managment and Remediation Staff_Screener.docx	Yes	Yes	Fillable Printable
Other-WORD	Attachment 9 Treating Clinician_Interview Guide.docx	No		Paper Only
Other-WORD	Attachment 10 Infection Control Clinician_Interview Guide.docx	No		Paper Only
Other-WORD	Attachment 11 Building Managers and Water Maintenance Staff_Interview Guide.docx	No		Paper Only
Other-WORD	Attachment 1 Treating Clinician_Screener.docx	Yes	Yes	Fillable Printable
Other-WORD	Attachment 2 Infection Control Clinician_Screener.docx	Yes	Yes	Fillable Printable
Other-WORD	Attachment 12 Water System Risk Management and Remediation Staff_Interview Guide.docx	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 144

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	144	144
Annual IC Time Burden (Hours)	66	66
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 5_Treating Clinician Consent	Attachment 5 Treating Clinician_Consent Form.doc	08/29/2016
Att 6_ Infection Control Clinician Consent	Attachment 6 Infection Control Clinician_Consent Form.doc	08/29/2016
Att 7_Building Mgr and Water Maint. Staff Consent	Attachment 7 Building Managers and Water Maintenance Staff_Consent Form.doc	08/29/2016
Att 8_Water System Risk Mgmt & Remediation Staff Consent	Attachment 8 Water System Risk Management and Remediation Staff_Consent Form.doc	08/29/2016
Att 13_Treating Clinician_Test materials	Attachment 13 Treating Clinician_Test Materials.pdf	08/29/2016
Att 14_Infection Control Clinician_Test materials	Attachment 14 Infection Control Clinician_Test Materials.pdf	08/29/2016
Att 15_Bldg Mgrs and Water Maint. Staff_ Test materials	Attachment 15 Building Managers and Water Maintenance Staff_Test Materials.pdf	08/29/2016
Att 16_Water Risk Mgmt and Remediation Staff_Test materials	Attachment 16 Water System Risk Management and Remediation Staff_Test Materials.pdf	08/29/2016
Att 17_Email Instructions_Interview Participation	Attachment 17 Email Instructions_Interview Participation.docx	08/29/2016
Att 18_Remote Testing Procedures	Attachment 18 Remote Testing Procedures.docx	08/29/2016
Supporting Statement A	SS A 2016 Legionella_8 29 2016 final.docx	08/29/2016
Supporting Statement B	SS B 2016 Legionella_8 29 2016 final.docx	08/29/2016

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