Emerging Infections Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
2015 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report	Form	New	Available
Community-associated Clostridium difficle Infection (CDI Surveillance Health Inter	Form	New	Repair queued
Screening Questions for Clostridium difficile Telephone Interview	Form	New	Available
EIP CDI Surveillance: CDI Case Treatment Questionnaire	Form	New	Available
Clostridium Difficile Infection (CDI) Surveillance Emerging Infections Program Case Report	Form	New	Available
Form CDC 52.15A 2015 Active Bacterial Core Surveillance (ABCs) Case Report Non-Bacteremic Pneumococcal Disease	Form	New	Available
Verbal Consent Form	Form	Modified	Available
Att 6_2014-15 Vaccination History Patient/Proxy Interview (English)	Form	Modified	Available
FluSurv-NET Case Report	Form	Modified	Available
Legionellosis Case Report	Form	Unchanged	Repair queued
Neonatal Tracking	Form	Unchanged	Available
Active Bacterial Core Surveillance (ABCs) Invasive Pneumococcal Disease in Children	Form	Modified	Available
Invasive Methicillin-Resistant Staph	Form	Unchanged	Available
Form CDC 52.15A 2015 Active Bacterial Core Surveillance (ABCs) Case Report	Form	Modified	Available
2015 CRF Changes Summary.xlsx	Supplementary Document	Uploaded 2015-01-16	Available
EIP 2015 Change Request_justification_revised 1-12-15.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-01-16	Available
Attachment 13 _ CDI ASSENT for 13-15.pdf	Supplementary Document	Uploaded 2015-01-16	Available
Attachment 12 _ADULT VERBAL CONSENT Assent 16_17 for CDI.PDF	Supplementary Document	Uploaded 2015-01-16	Available
Attachment 04_FoodNet Variable List_2014_12312013.pdf	Supplementary Document	Uploaded 2015-01-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
214679	Att16_Resistant Gram-Negative Bacilli Case Report Form	Form	New	2015 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report
214678	Att 15_CDI Telephone Interview	Form	New	Community-associated Clostridium difficle Infection (CDI Surveillance Health Inter
214677	Att 14_CDI Screening Form	Form	New	Screening Questions for Clostridium difficile Telephone Interview
214676	Att 11_CDI Treatment Form	Form	New	EIP CDI Surveillance: CDI Case Treatment Questionnaire
214675	Att 10_CDI Case Report Form	Form	New	Clostridium Difficile Infection (CDI) Surveillance Emerging Infections Program Case Report
214674	Att 3_2015 Active Bacterial Core Surveillance (ABCs) Case Report Non-Bacteremic Pneumoccoccal Disease	Form	New	2015 Active Bacterial Core Surveillance (ABCs) Case Report Non-Bacteremic Pneumococcal Disease
207663	Yersinia	Other-WORD	Unchanged
207662	Vibrio	Other-WORD	Unchanged
207661	Shigella	Other-WORD	Unchanged
207660	Shiga toxin producing E. coli	Other-WORD	Unchanged
207659	Salmonella	Other-WORD	Unchanged
207658	Listeria monocytogenes	Other-WORD	Unchanged
207657	Cyclospora	Other-WORD	Unchanged
207656	Cryptosporidium	Other-WORD	Unchanged
207655	Campylobacter	Other-WORD	Unchanged
207654	Att 8_FluSurv-Net Project Consent Form	Form	Modified	Verbal Consent Form
207653	Att 6_2014-15 Vaccination History Patient/Proxy Interview	Form	Modified	Att 6_2014-15 Vaccination History Patient/Proxy Interview (English)
207652	Hemolytic Uremic Syndrome (HUS)	Other-WORD	Unchanged
207651	Att 5_FluSurv-NET Influenza Hospitalization Surveilance Project Case Report Form	Form	Modified	FluSurv-NET Case Report
207650	Legionellosis ABCs Case Report	Form	Unchanged	Legionellosis Case Report
207649	ABCs Neonatal Infection Expanded Tracking Form	Form	Unchanged	Neonatal Tracking
207648	Att 2_ABCs Invasive Pneumococcal Disease in Children	Form	Modified	Active Bacterial Core Surveillance (ABCs) Invasive Pneumococcal Disease in Children
207647	Invasive Methicillin - Resistant - Staphylococcus aureus ABCs Case Report Form	Form	Unchanged	Invasive Methicillin-Resistant Staph
207646	Att 1_ABCs Case Report Form	Form	Modified	2015 Active Bacterial Core Surveillance (ABCs) Case Report

ICR Details

OMB Control No: 0920-0978	ICR Reference No: 201501-0920-018
Status: Historical Inactive	Previous ICR Reference No: 201402-0920-016
Agency/Subagency: HHS/CDC	Agency Tracking No: 15FZ
Title: Emerging Infections Program
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 01/29/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/22/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2016	08/31/2016	08/31/2016
Responses	41,200	0	41,200
Time Burden (Hours)	12,319	0	12,319
Cost Burden (Dollars)	0	0	0

---

Abstract: CDC is requesting minor changes for 2015 reporting of diseases reported under the Emerging Infections Program.

---

Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 24

table that charts list of burden

IC Title	Form No.	Form Name
ABCs Neonatal Infection Expanded Tracking Form	none	Neonatal Tracking
Att 10_CDI Case Report Form	None	Clostridium Difficile Infection (CDI) Surveillance Emerging Infections Program Case Report
Att 11_CDI Treatment Form	None	EIP CDI Surveillance: CDI Case Treatment Questionnaire
Att 14_CDI Screening Form	None	Screening Questions for Clostridium difficile Telephone Interview
Att 15_CDI Telephone Interview	None	Community-associated Clostridium difficle Infection (CDI Surveillance Health Inter
Att 1_ABCs Case Report Form	CDC 52.15A	2015 Active Bacterial Core Surveillance (ABCs) Case Report
Att 2_ABCs Invasive Pneumococcal Disease in Children	None	Active Bacterial Core Surveillance (ABCs) Invasive Pneumococcal Disease in Children
Att 3_2015 Active Bacterial Core Surveillance (ABCs) Case Report Non-Bacteremic Pneumoccoccal Disease	CDC 52.15A	2015 Active Bacterial Core Surveillance (ABCs) Case Report Non-Bacteremic Pneumococcal Disease
Att 5_FluSurv-NET Influenza Hospitalization Surveilance Project Case Report Form	none	FluSurv-NET Case Report
Att 6_2014-15 Vaccination History Patient/Proxy Interview	none	Att 6_2014-15 Vaccination History Patient/Proxy Interview (English)
Att 8_FluSurv-Net Project Consent Form	None	Verbal Consent Form
Att16_Resistant Gram-Negative Bacilli Case Report Form	None	2015 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report
Campylobacter
Cryptosporidium
Cyclospora
Hemolytic Uremic Syndrome (HUS)
Invasive Methicillin - Resistant - Staphylococcus aureus ABCs Case Report Form	none	Invasive Methicillin-Resistant Staph
Legionellosis ABCs Case Report	none	Legionellosis Case Report
Listeria monocytogenes
Salmonella
Shiga toxin producing E. coli
Shigella
Vibrio
Yersinia

---

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: Yes

Burden Reduction Due to: Changing Forms

Short Statement: Requesting approval of a non-substantive change to modify forms and make minor burden changes. These forms are use to conduct surveillance to determine the incidence and epidemiologic characteristics of invasive diseases.

---

Annual Cost to Federal Government: $6,872,123

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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

---

Common Form ICR:  No

---

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: 01/22/2015

---