Information Collection

EVD Tracking Form for Healthcare Workers with Direct Patient Contact

IC 214551 under ICR 201501-0920-006 · OMB 0920-1045.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
EVD Tracking Form for Healthcare Workers with Direct Patient Contact	Form and Instruction
Contact Tracing Form for Health Care Workers caring for Att5a EVD Tracking Form for HCWs.xlsx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Contact Tracing Form for Health Care Workers caring for Ebola patients	Att5a EVD Tracking Form for HCWs.xlsx	None	Yes	Yes	Fillable Fileable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records

Title: 09-20-0113 Epidemic Investigation Case Record Systems Notice

FR Citation: 51 FR 42466

Number of Respondents: 300

Number of Respondents for Small Entity: 300

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,500	4,500
Annual IC Time Burden (Hours)	750	750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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