Information Collection Request

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

ICR 201501-0920-017 · OMB 0920-1033 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 0920-1033 Att D HCW.EVD.expriskreport_SierraLeone Form and Instruction New Available
Form 0920-1033 Att C HCW.Ebola.virus.invest.questionnaire_Liberia Form and Instruction New Available
Form 0920-1033 Att B1 HCW.EVD.expriskreport_WestAfrica v10 Eng Translation Form and Instruction New Available
Form 0920-1033 Att B HCW.EVD.expriskreport_WestAfrica v10 French Form and Instruction New Available
Form 0920-1033 Att A HCW.EVD.expriskreport_WestAfrica Form and Instruction New Available
Form 0920-15CN Attachment M_Health Facility Assessment and Case Finding Survey Form and Instruction Unchanged Available
Form 0920-15CN Attachment L_Ebola Virus Disease Case Contact Questionnaire Form and Instruction Unchanged Available
Form 0920-15CN Attachment N_Viral Hemorrhagic Fever Contact Tracing Follow-Up Form Form and Instruction Unchanged Available
Form 0920-15CN Attachment K_Viral Hemorrhagic Fever Contact Listing Form_Liberia Form and Instruction Unchanged Available
Form 0920-15CN Attachment J_Viral Hemorrhagic Fever Contact Listing Form_Guinea_French Form and Instruction Unchanged Available
Form 0920-15CN Attachment I_Viral Hemorrhagic Fever Contact Listing Form_Senegal_French Form and Instruction Unchanged Available
Form 0920-15CN Attachment H_Viral Hemorrhagic Fever Contact Listing Form_General Form and Instruction Unchanged Available
Form 0920-15CN Attachment G_Viral Hemorrhagic Fever Case Investigation Form_Short Version_Liberia Form and Instruction Unchanged Available
Form 0920-15CN Attachment F_Viral Hemorrhagic Fever Case Investigation Form_Nigeria Form and Instruction Unchanged Available
Form 0920-15CN Attachment E_Viral Hemorrhagic Fever Case Investigation Form_Sierra Leone Form and Instruction Unchanged Available
Form 0920-15CN Attachment D_Viral Hemorrhagic Fever Case Investigation Form_Liberia (2) Form and Instruction Unchanged Available
Form 0920-15CN Attachment C_Viral Hemorrhagic Fever Case Investigation Form_Senegal_French Form and Instruction Unchanged Available
Form 0920-15CN Attachment B_Viral Hemorrhagic Fever Case Investigation Form_Guinea_French Form and Instruction Unchanged Available
non-Substantive Change Request to 0920-1033 1-14-15.docx Justification for No Material/Nonsubstantive Change Uploaded 2015-01-16 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 IDCollectionTypeStatusForm
214673 Healthcare Worker- Ebola Virus Disease Exposure Risk Report - Sierra Leone Form and Instruction NewAtt D HCW.EVD.expriskreport_SierraLeone
214672 Healthcare Worker-Ebola Virus Disease Investigation Questionnaire - Liberia Form and Instruction NewAtt C HCW.Ebola.virus.invest.questionnaire_Liberia
214671 Healhcare Worker-Ebola Virus Disease Exposure Risk Report (CDC/WHO) - French Form and Instruction NewAtt B1 HCW.EVD.expriskreport_WestAfrica v10 Eng Translation
214671 Healhcare Worker-Ebola Virus Disease Exposure Risk Report (CDC/WHO) - French Form and Instruction NewAtt B HCW.EVD.expriskreport_WestAfrica v10 French
214670 Healthcare Worker-Ebola Virus Disease Exposure Risk Report (CDC/WHO) Form and Instruction NewAtt A HCW.EVD.expriskreport_WestAfrica
213621 Health Facility Assessment and Case Finding Survey Form and Instruction UnchangedAttachment M_Health Facility Assessment and Case Finding Survey
213620 Ebola Virus Disease Case Contact Questionnaire Form and Instruction UnchangedAttachment L_Ebola Virus Disease Case Contact Questionnaire
213619 Viral Hemorrhagic Fever Contact Tracing Follow-Up Form Form and Instruction UnchangedAttachment N_Viral Hemorrhagic Fever Contact Tracing Follow-Up Form
213618 Viral Hemorrhagic Fever Contact Listing Form (Liberia) Form and Instruction UnchangedAttachment K_Viral Hemorrhagic Fever Contact Listing Form_Liberia
213617 Viral Hemorrhagic Fever Contact Listing Form (Guinea French) Form and Instruction UnchangedAttachment J_Viral Hemorrhagic Fever Contact Listing Form_Guinea_French
213616 Viral Hemorrhagic Fever Contact Listing Form (Senegal French) Form and Instruction UnchangedAttachment I_Viral Hemorrhagic Fever Contact Listing Form_Senegal_French
213615 Viral Hemorrhagic Fever Contact Listing Form (General) Form and Instruction UnchangedAttachment H_Viral Hemorrhagic Fever Contact Listing Form_General
213614 Viral Hemorrhagic Fever Case Investigation Form (Short Version Liberia) Form and Instruction UnchangedAttachment G_Viral Hemorrhagic Fever Case Investigation Form_Short Version_Liberia
213613 Viral Hemorrhagic Fever Case Investigation Form (Nigeria) Form and Instruction UnchangedAttachment F_Viral Hemorrhagic Fever Case Investigation Form_Nigeria
213612 Viral Hemorrhagic Fever Case Investigation Form (Sierra Leone) Form and Instruction UnchangedAttachment E_Viral Hemorrhagic Fever Case Investigation Form_Sierra Leone
213611 Viral Hemorrhagic Fever Case Investigation Form (Liberia) Form and Instruction UnchangedAttachment D_Viral Hemorrhagic Fever Case Investigation Form_Liberia (2)
213609 Viral Hemorrhagic Fever Case Investigation Form (Senegal French) Form and Instruction UnchangedAttachment C_Viral Hemorrhagic Fever Case Investigation Form_Senegal_French
213607 Viral Hemorrhagic Fever Case Investigation Form (Guinea French) Form and Instruction UnchangedAttachment B_Viral Hemorrhagic Fever Case Investigation Form_Guinea_French

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
04/30/2015 6 Months From Approved 04/30/2015
298,650 0 297,850
54,679 0 54,279
0 0 0





Reginfo record details
17
table that charts list of burden
IC Title Form No. Form Name
Ebola Virus Disease Case Contact Questionnaire 0920-15CN
Healhcare Worker-Ebola Virus Disease Exposure Risk Report (CDC/WHO) - French 0920-1033, 0920-1033 ,  
Health Facility Assessment and Case Finding Survey 0920-15CN
Healthcare Worker- Ebola Virus Disease Exposure Risk Report - Sierra Leone 0920-1033
Healthcare Worker-Ebola Virus Disease Exposure Risk Report (CDC/WHO) 0920-1033
Healthcare Worker-Ebola Virus Disease Investigation Questionnaire - Liberia 0920-1033
Viral Hemorrhagic Fever Case Investigation Form (Guinea French) 0920-15CN
Viral Hemorrhagic Fever Case Investigation Form (Liberia) 0920-15CN
Viral Hemorrhagic Fever Case Investigation Form (Nigeria) 0920-15CN
Viral Hemorrhagic Fever Case Investigation Form (Senegal French) 0920-15CN
Viral Hemorrhagic Fever Case Investigation Form (Short Version Liberia) 0920-15CN
Viral Hemorrhagic Fever Case Investigation Form (Sierra Leone) 0920-15CN
Viral Hemorrhagic Fever Contact Listing Form (General) 0920-15CN
Viral Hemorrhagic Fever Contact Listing Form (Guinea French) 0920-15CN
Viral Hemorrhagic Fever Contact Listing Form (Liberia) 0920-15CN
Viral Hemorrhagic Fever Contact Listing Form (Senegal French) 0920-15CN
Viral Hemorrhagic Fever Contact Tracing Follow-Up Form 0920-15CN

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 298,650 297,850 0 800 0 0
Annual Time Burden (Hours) 54,679 54,279 0 400 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No