Att 8_FluSurv-Net Project Consent Form

Emerging Infections Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:

Documents and Forms

Document Name Document Type
Att 8_FluSurv-Net Project Consent Form Form
Verbal Consent Form Attachment 08_2014-15 FluSurv-NET Surveillance Project Consent(ENG).pdf Form
Attachment 09_2014-15 FluSurv-NET Surveillance Project Consent(SPAN).pdf Att 9_Verbal Consent Form (Spanish) IC Document

Information Collection (IC) Details

IC Title:	Att 8_FluSurv-Net Project Consent Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	None	Verbal Consent Form	Attachment 08_2014-15 FluSurv-NET Surveillance Project Consent(ENG).pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 9_Verbal Consent Form (Spanish)	Attachment 09_2014-15 FluSurv-NET Surveillance Project Consent(SPAN).pdf	01/16/2015

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