Ebola Virus Disease in the United States:CDC Support for Case and Contact Investigation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
EVD Contact Tracing Form - United States	Form and Instruction	New	Available
EVD Case Investigation Form - United States	Form and Instruction	New	Available
Daily White House Report	Form and Instruction	New	Available
Symptom Monitoring Form	Form and Instruction	New	Available
Contact Trakcing Form for Environmental Services Personnel	Form and Instruction	New	Available
Symptom Monitoring Form	Form and Instruction	New	Available
Ebola Tracking Form for Laboratory Personnel	Form and Instruction	New	Available
Symptom Monitoring Form	Form and Instruction	New	Available
Contact Tracing Form for Health Care Workers caring for Ebola patients	Form and Instruction	New	Available
Symptom Monitoring Form	Form and Instruction	New	Available
Person Under Investigation (PUI) for Ebola Form - United States	Form and Instruction	New	Available
SupStmnt A US EVD CaseContInvest 20150123.docx	Supporting Statement A	Uploaded 2015-01-24	Available
Appndx2b ASTHO cmmnts CDC response 14JAN2015.docx	Supplementary Document	Uploaded 2015-01-14	Available
Appndx2a CSTE cmmnts CDC rsponse 14JAN2015.docx	Supplementary Document	Uploaded 2015-01-14	Available
SupStmnt B US EVD CaseContInvest 20150123.docx	Supporting Statement B	Uploaded 2015-01-24	Available
Att7 Generic End-of-Monitoring Letter.docx	Supplementary Document	Uploaded 2015-01-09	Available
Att4b Info for HCWs Treating Ebola Patients.docx	Supplementary Document	Uploaded 2015-01-09	Available
Att4a Guidance for Contacts of Ebola Patients.docx	Supplementary Document	Uploaded 2015-01-09	Available
Att3cGuidance for Eval Triage of Ebola Contacts.docx	Supplementary Document	Uploaded 2015-01-09	Available
Att3b Guidance for Eval Triage of Ebola Contacts.docx	Supplementary Document	Uploaded 2015-01-09	Available
Att3a Guidance for HD DA-AM of Returned Travelers.docx	Supplementary Document	Uploaded 2015-01-09	Available
Appndx3 SORN 09-20-0113 Epidemic Invest Case Records.pdf	Supplementary Document	Uploaded 2015-01-09	Available
Appndx1 42 USC 241 PH Service Act Section 301.pdf	Supplementary Document	Uploaded 2015-01-09	Available
Appndx2c_NACCHOcomments.docx	Supplementary Document	Uploaded 2015-01-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
214741	EVD Contact Tracing Investigation Form	Form and Instruction	New	EVD Contact Tracing Form - United States
214740	EVD Case Investigation Form - United States	Form and Instruction	New	EVD Case Investigation Form - United States
214557	White House Evening Report	Form and Instruction	New	Daily White House Report
214556	Symptom Monitoring Form - Environmental Lab Personnel	Form and Instruction	New	Symptom Monitoring Form
214555	EVD Tracking Form for Environmental Services Personnel	Form and Instruction	New	Contact Trakcing Form for Environmental Services Personnel
214554	Symptom Monitoring Form - Lab Personnel	Form and Instruction	New	Symptom Monitoring Form
214553	EVD Tracking Form for Laboratory Personnel	Form and Instruction	New	Ebola Tracking Form for Laboratory Personnel
214552	Symptom Monitoring Form - Health Care Workers	Form and Instruction	New	Symptom Monitoring Form
214551	EVD Tracking Form for Healthcare Workers with Direct Patient Contact	Form and Instruction	New	Contact Tracing Form for Health Care Workers caring for Ebola patients
214550	Symptom Monitoring Form	Form and Instruction	New	Symptom Monitoring Form
214548	Ebola Virus Disease Person Under Investigation (PUI) Form	Form and Instruction	New	Person Under Investigation (PUI) for Ebola Form - United States

ICR Details

OMB Control No: 0920-1045	ICR Reference No: 201501-0920-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15GW
Title: Ebola Virus Disease in the United States:CDC Support for Case and Contact Investigation
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: 01/16/2015
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/26/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/14/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2015	6 Months From Approved
Responses	54,073	0	0
Time Burden (Hours)	5,680	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The CDC is seeking emergency OMB clearance to effectively complement its ongoing international and travel-related efforts for rapid case identification, contact tracing, and infection control of Ebola virus disease (EVD) in West Africa, now emerging within the US through travel-related routes. The CDC has developed a toolkit of standardized forms and guides for state, territorial, and local (STL) public health authorities to consider using whenever and wherever active monitoring for EVD must occur. These forms will be used whenever CDC is requested by STL public health authorities or by another federal agency to assist in the control and prevention of future EVD outbreaks. CDC has developed forms to collect case and contact information from several types of respondents that may require monitoring for EVD [general public including EVD cases, persons under investigation (PUI), contacts of an EVD case; healthcare workers (HCWs) with direct EVD patient contact; laboratory personnel; and environmental services personnel]. In addition, the CDC requests that STL public health authorities and their delegates provide daily reports of active surveillance updates to maintain situational awareness of EVD in the U.S.

Emergency Justfication: This is an emergency request for 180-day OMB approval to allow the Centers for Disease Control and Prevention (CDC) to provide uninterrupted emergency support for domestic Ebola virus disease (EVD) case investigation and contact tracing activities on behalf of state, territorial, and local public health authorities in the United States (U.S.). As of December, 2014, continued federal assistance in West Africa indicates that domestic screening and monitoring of travelers from Ebola-affected countries and their contacts here in the U.S. remains a public health priority.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: US 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: 11

table that charts list of burden

IC Title	Form No.	Form Name
EVD Case Investigation Form - United States	None	EVD Case Investigation Form - United States
EVD Contact Tracing Investigation Form	None	EVD Contact Tracing Form - United States
EVD Tracking Form for Environmental Services Personnel	None	Contact Trakcing Form for Environmental Services Personnel
EVD Tracking Form for Healthcare Workers with Direct Patient Contact	None	Contact Tracing Form for Health Care Workers caring for Ebola patients
EVD Tracking Form for Laboratory Personnel	None	Ebola Tracking Form for Laboratory Personnel
Ebola Virus Disease Person Under Investigation (PUI) Form	None	Person Under Investigation (PUI) for Ebola Form - United States
Symptom Monitoring Form	None	Symptom Monitoring Form
Symptom Monitoring Form - Environmental Lab Personnel	None	Symptom Monitoring Form
Symptom Monitoring Form - Health Care Workers	None	Symptom Monitoring Form
Symptom Monitoring Form - Lab Personnel	None	Symptom Monitoring Form
White House Evening Report	None	Daily White House Report

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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	54,073	0	0	54,073	0	0
Annual Time Burden (Hours)	5,680	0	0	5,680	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: Submission 0920-15GW is a New ICR

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Annual Cost to Federal Government: $165,656

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: 01/14/2015

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