2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-15CN Attachment M_Health Facility Assessment and Case Finding Survey	Form and Instruction	New	Available
Form 0920-15CN Attachment L_Ebola Virus Disease Case Contact Questionnaire	Form and Instruction	New	Available
Form 0920-15CN Attachment N_Viral Hemorrhagic Fever Contact Tracing Follow-Up Form	Form and Instruction	New	Available
Form 0920-15CN Attachment K_Viral Hemorrhagic Fever Contact Listing Form_Liberia	Form and Instruction	New	Available
Form 0920-15CN Attachment J_Viral Hemorrhagic Fever Contact Listing Form_Guinea_French	Form and Instruction	New	Available
Form 0920-15CN Attachment I_Viral Hemorrhagic Fever Contact Listing Form_Senegal_French	Form and Instruction	New	Repair queued
Form 0920-15CN Attachment H_Viral Hemorrhagic Fever Contact Listing Form_General	Form and Instruction	New	Available
Form 0920-15CN Attachment G_Viral Hemorrhagic Fever Case Investigation Form_Short Version_Liberia	Form and Instruction	New	Available
Form 0920-15CN Attachment F_Viral Hemorrhagic Fever Case Investigation Form_Nigeria	Form and Instruction	New	Available
Form 0920-15CN Attachment E_Viral Hemorrhagic Fever Case Investigation Form_Sierra Leone	Form and Instruction	New	Available
Form 0920-15CN Attachment D_Viral Hemorrhagic Fever Case Investigation Form_Liberia (2)	Form and Instruction	New	Available
Form 0920-15CN Attachment C_Viral Hemorrhagic Fever Case Investigation Form_Senegal_French	Form and Instruction	New	Available
Form 0920-15CN Attachment B_Viral Hemorrhagic Fever Case Investigation Form_Guinea_French	Form and Instruction	New	Available
Attachment O_Ebola Virus Epi Invest SORN_10-06-2014.doc	Supplementary Document	Uploaded 2014-10-23	Available
International_Ebola Emergency Clearance SSA Final.docx	Supporting Statement B	Uploaded 2014-10-23	Available
International_Ebola Emergency Clearance SSA Final.docx	Supporting Statement A	Uploaded 2014-10-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
213621	Health Facility Assessment and Case Finding Survey	Form and Instruction	New	Attachment M_Health Facility Assessment and Case Finding Survey
213620	Ebola Virus Disease Case Contact Questionnaire	Form and Instruction	New	Attachment L_Ebola Virus Disease Case Contact Questionnaire
213619	Viral Hemorrhagic Fever Contact Tracing Follow-Up Form	Form and Instruction	New	Attachment N_Viral Hemorrhagic Fever Contact Tracing Follow-Up Form
213618	Viral Hemorrhagic Fever Contact Listing Form (Liberia)	Form and Instruction	New	Attachment K_Viral Hemorrhagic Fever Contact Listing Form_Liberia
213617	Viral Hemorrhagic Fever Contact Listing Form (Guinea French)	Form and Instruction	New	Attachment J_Viral Hemorrhagic Fever Contact Listing Form_Guinea_French
213616	Viral Hemorrhagic Fever Contact Listing Form (Senegal French)	Form and Instruction	New	Attachment I_Viral Hemorrhagic Fever Contact Listing Form_Senegal_French
213615	Viral Hemorrhagic Fever Contact Listing Form (General)	Form and Instruction	New	Attachment H_Viral Hemorrhagic Fever Contact Listing Form_General
213614	Viral Hemorrhagic Fever Case Investigation Form (Short Version Liberia)	Form and Instruction	New	Attachment G_Viral Hemorrhagic Fever Case Investigation Form_Short Version_Liberia
213613	Viral Hemorrhagic Fever Case Investigation Form (Nigeria)	Form and Instruction	New	Attachment F_Viral Hemorrhagic Fever Case Investigation Form_Nigeria
213612	Viral Hemorrhagic Fever Case Investigation Form (Sierra Leone)	Form and Instruction	New	Attachment E_Viral Hemorrhagic Fever Case Investigation Form_Sierra Leone
213611	Viral Hemorrhagic Fever Case Investigation Form (Liberia)	Form and Instruction	New	Attachment D_Viral Hemorrhagic Fever Case Investigation Form_Liberia (2)
213609	Viral Hemorrhagic Fever Case Investigation Form (Senegal French)	Form and Instruction	New	Attachment C_Viral Hemorrhagic Fever Case Investigation Form_Senegal_French
213607	Viral Hemorrhagic Fever Case Investigation Form (Guinea French)	Form and Instruction	New	Attachment B_Viral Hemorrhagic Fever Case Investigation Form_Guinea_French

ICR Details

OMB Control No: 0920-1033	ICR Reference No: 201410-0920-027
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-15CN
Title: 2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 10/24/2014
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/24/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/24/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2015	6 Months From Approved
Responses	297,850	0	0
Time Burden (Hours)	54,279	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: On March 21, 2014, the World Health Organization (WHO) and the Ministry of Health (MoH) of Guinea reported an outbreak of Ebola viral disease (EVD), and shortly thereafter clinical cases were also reported in Liberia. By May, the first cases identified in Sierra Leone were reported. The outbreak expanded to Nigeria on July 25th and Senegal on August 29th. The outbreak continues to accelerate in West Africa and is unprecedented in size. This emergency ICR is an extension of several collections started under OMB Control Number 0920-1011, "Emergency Epidemic Investigation Data Collections," and will allow CDC to continue ongoing work.

Emergency Justfication: WHO has declared the Ebola outbreak in West Africa to be an international public health emergency. The 2014 Ebola outbreak is unprecedented and the first in West Africa. CDC is currently assisting with the investigation, by taking active steps to respond to the rapidly changing situation internationally and domestically by working with other U.S. government agencies, the World Health Organization, and other domestic and international partners to identify sources and risk factors for Ebola infection in order to implement prevention and control measures. The epidemiological objectives are to maintain a centralized database for data collected from all outbreak sites, domestic and international to assist in contact tracing, case report collection, and patient or family interviews.

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 13

table that charts list of burden

IC Title	Form No.	Form Name
Ebola Virus Disease Case Contact Questionnaire	0920-15CN	Attachment L_Ebola Virus Disease Case Contact Questionnaire
Health Facility Assessment and Case Finding Survey	0920-15CN	Attachment M_Health Facility Assessment and Case Finding Survey
Viral Hemorrhagic Fever Case Investigation Form (Guinea French)	0920-15CN	Attachment B_Viral Hemorrhagic Fever Case Investigation Form_Guinea_French
Viral Hemorrhagic Fever Case Investigation Form (Liberia)	0920-15CN	Attachment D_Viral Hemorrhagic Fever Case Investigation Form_Liberia (2)
Viral Hemorrhagic Fever Case Investigation Form (Nigeria)	0920-15CN	Attachment F_Viral Hemorrhagic Fever Case Investigation Form_Nigeria
Viral Hemorrhagic Fever Case Investigation Form (Senegal French)	0920-15CN	Attachment C_Viral Hemorrhagic Fever Case Investigation Form_Senegal_French
Viral Hemorrhagic Fever Case Investigation Form (Short Version Liberia)	0920-15CN	Attachment G_Viral Hemorrhagic Fever Case Investigation Form_Short Version_Liberia
Viral Hemorrhagic Fever Case Investigation Form (Sierra Leone)	0920-15CN	Attachment E_Viral Hemorrhagic Fever Case Investigation Form_Sierra Leone
Viral Hemorrhagic Fever Contact Listing Form (General)	0920-15CN	Attachment H_Viral Hemorrhagic Fever Contact Listing Form_General
Viral Hemorrhagic Fever Contact Listing Form (Guinea French)	0920-15CN	Attachment J_Viral Hemorrhagic Fever Contact Listing Form_Guinea_French
Viral Hemorrhagic Fever Contact Listing Form (Liberia)	0920-15CN	Attachment K_Viral Hemorrhagic Fever Contact Listing Form_Liberia
Viral Hemorrhagic Fever Contact Listing Form (Senegal French)	0920-15CN	Attachment I_Viral Hemorrhagic Fever Contact Listing Form_Senegal_French
Viral Hemorrhagic Fever Contact Tracing Follow-Up Form	0920-15CN	Attachment N_Viral Hemorrhagic Fever Contact Tracing Follow-Up Form

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ICR Summary of Burden

table that charts list 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	297,850	0	0	297,850	0	0
Annual Time Burden (Hours)	54,279	0	0	54,279	0	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: No

Burden Reduction Due to:

Short Statement: This is a New Emergency Clearance request

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Annual Cost to Federal Government: $339,695

Does this IC contain surveys, censuses, or employ statistical methods? No

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

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Common Form ICR:  No

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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: 10/24/2014

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