2014005XXX_DiarrhealDisease_AS

Emergency Epidemic Investigation Data Collections - Expedited Reviews

⚠️ Notice: This information collection may be referencing outdated material.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
2014005XXX_DiarrhealDisease_AS Form
Medical Abstraction Form Attachment 1-Medical Chart Abstraction Form.docx Form
Case Questionnaire Attachment 2-Case questionnaire.doc Form
American Samoa Epi-Aid Request 5-23-14.pdf Letter of Invitation IC Document
2014005XXX_DiarrhealDisease_AS.docx Request for Approval IC Document

Information Collection (IC) Details

IC Title:	2014005XXX_DiarrhealDisease_AS	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR USC 301 [241] (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Medical Abstraction Form	Attachment 1-Medical Chart Abstraction Form.docx		No		Paper Only
Form	none	Case Questionnaire	Attachment 2-Case questionnaire.doc		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0113 Epidemic Investigations Case Records System Notice	FR Citation: 51 FR 42466

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	117	117
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Letter of Invitation	American Samoa Epi-Aid Request 5-23-14.pdf	05/23/2014
Request for Approval	2014005XXX_DiarrhealDisease_AS.docx	05/23/2014

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