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⚠️ Notice: This information collection may be referencing outdated material.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

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:

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 %

	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

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.