Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Ebola Entry Screening Risk Assessment Form - Arabic	Form and Instruction	New	Available
Ebola Entry Screening Risk Assessment Form - French	Form and Instruction	New	Available
Ebola Entry Screening Risk Assessment Form - English	Form and Instruction	New	Available
Ebola Entry Screening Risk Assessment Form - Arabic	Form and Instruction	New	Available
Ebola Entry Screening Risk Assessment Form - French	Form and Instruction	New	Repair queued
Ebola Entry Screening Risk Assessment Form - English	Form and Instruction	New	Available
United States Traveler Health Declaration - Arabic Translation Guide	Form and Instruction	New	Available
United States Traveler Health Declaration - French Translation Guide	Form and Instruction	New	Available
United States Health Declaration - English/PDF	Form and Instruction	New	Available
United States Traveler Health Declaration - English/Portal	Form and Instruction	New	Repair queued
United States Traveler Health Declaration - English/Hard Copy	Form and Instruction	New	Available
Risk Assessment for Travelers from Ebola-Affected Countries	Form	Removed	Available
Air Travel Illness or Death Investigation	Form	Unchanged	Available
Land Travel Illness or Death Investigation	Form	Unchanged	Repair queued
Form 0920-0821 Attachment A Maritime investigation form	Form and Instruction	Unchanged	Available
0920-0821 Revision Part A 02102015 tracked.doc	Supporting Statement A	Uploaded 2015-02-10	Available
Attachment B1 Comment to Federal Register 12022014.docx	Supplementary Document	Uploaded 2015-02-06	Available
Attachment J Non-research Determination.pdf	Supplementary Document	Uploaded 2015-02-06	Available
Attachment B 60 day FRN 0821.pdf	Supplementary Document	Uploaded 2015-02-06	Available
Attachment A3 CFR-2013-title42-vol1-part71.pdf	Supplementary Document	Uploaded 2015-02-06	Repair queued
Attachment A2 CFR-2013-title42-vol1-part70.pdf	Supplementary Document	Uploaded 2015-02-06	Available
Attachment A1 USCODE-2009-title42-chap6A-subchapII-partG.PDF	Supplementary Document	Uploaded 2015-02-06	Repair queued
0920-0821 Revision Part B 02042015 tracked.docx	Supporting Statement B	Uploaded 2015-02-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
214908	Ebola Entry Screening Risk Assessment (Ill Traveler Interview)	Form and Instruction	New	Ebola Entry Screening Risk Assessment Form - Arabic
214908	Ebola Entry Screening Risk Assessment (Ill Traveler Interview)	Form and Instruction	New	Ebola Entry Screening Risk Assessment Form - French
214908	Ebola Entry Screening Risk Assessment (Ill Traveler Interview)	Form and Instruction	New	Ebola Entry Screening Risk Assessment Form - English
214903	IVR Active Monitoring Survey - ARABIC (for translation service)	Other-IVR Telephone Survey Script (Limited number - English for	New
214902	IVR Active Monitoring Survey - FRENCH	Other-IVR Telephone Survey Script - French	New
214901	IVR Active Monitoring Survey - ENGLISH	Other-IVR Telephone Survey Script - English	New
214898	Ebola Entry Screening Risk Assessment - ARABIC	Form and Instruction	New	Ebola Entry Screening Risk Assessment Form - Arabic
214896	Ebola Entry Screening Risk Assessment - FRENCH	Form and Instruction	New	Ebola Entry Screening Risk Assessment Form - French
214895	Ebola Entry Screening Risk Assessment - ENGLISH	Form and Instruction	New	Ebola Entry Screening Risk Assessment Form - English
214893	United States Traveler Health Declaration - ARABIC	Form and Instruction	New	United States Traveler Health Declaration - Arabic Translation Guide
214890	United States Traveler Health Declaration - FRENCH	Form and Instruction	New	United States Traveler Health Declaration - French Translation Guide
214888	United States Traveler Health Declaration - ENGLISH	Form and Instruction	New	United States Health Declaration - English/PDF
214888	United States Traveler Health Declaration - ENGLISH	Form and Instruction	New	United States Traveler Health Declaration - English/Portal
214888	United States Traveler Health Declaration - ENGLISH	Form and Instruction	New	United States Traveler Health Declaration - English/Hard Copy
213021	Exposure Risk Assessment for Travelers from Ebola-Affected Countries	Form	Removed	Risk Assessment for Travelers from Ebola-Affected Countries
188000	Air Travel Illness or Death Investigation	Form	Unchanged	Air Travel Illness or Death Investigation
187999	Land Travel Illness or Death Investigation	Form	Unchanged	Land Travel Illness or Death Investigation
187997	International Maritime Illness or Death Investigation	Form and Instruction	Unchanged	Attachment A Maritime investigation form

ICR Details

OMB Control No: 0920-0821	ICR Reference No: 201502-0920-002
Status: Historical Active	Previous ICR Reference No: 201409-0920-006
Agency/Subagency: HHS/CDC	Agency Tracking No: 19217
Title: Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/10/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/11/2015
Terms of Clearance: This ICR is approved for one year -- justification related to a public health need will need to be provided at that time for continued use of the Ebola screening forms. If CDC stops using them during this year, they should submit a change request ending their use.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2016	36 Months From Approved	08/31/2015
Responses	1,129,429	0	3,858
Time Burden (Hours)	85,382	0	319
Cost Burden (Dollars)	0	0	0

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Abstract: Quarantine station staff work in partnership with international, federal, state, and local agencies and organizations to fulfill their mission to reduce morbidity and mortality among immigrants, refugees, travelers, expatriates, and other globally mobile persons. This request for change is to add the Exposure Risk Assessment for Travelers from Ebola Outbreak-Affected countries.

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Authorizing Statute(s): US Code: 42 USC 264 Name of Law: Regulations to Control Communicable Diseases
   US Code: 42 USC 71 Name of Law: Foreign Quarantine
   US Code: 42 USC 70 Name of Law: Interstate Quarrantine
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 71430	12/02/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 7474	02/10/2015
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 13

table that charts list of burden

IC Title	Form No.	Form Name
Air Travel Illness or Death Investigation	none	Air Travel Illness or Death Investigation
Ebola Entry Screening Risk Assessment (Ill Traveler Interview)	None, None, None	Ebola Entry Screening Risk Assessment Form - English ,   Ebola Entry Screening Risk Assessment Form - French ,   Ebola Entry Screening Risk Assessment Form - Arabic
Ebola Entry Screening Risk Assessment - ARABIC	None	Ebola Entry Screening Risk Assessment Form - Arabic
Ebola Entry Screening Risk Assessment - ENGLISH	None	Ebola Entry Screening Risk Assessment Form - English
Ebola Entry Screening Risk Assessment - FRENCH	None	Ebola Entry Screening Risk Assessment Form - French
Exposure Risk Assessment for Travelers from Ebola-Affected Countries	none	Risk Assessment for Travelers from Ebola-Affected Countries
IVR Active Monitoring Survey - ARABIC (for translation service)
IVR Active Monitoring Survey - ENGLISH
IVR Active Monitoring Survey - FRENCH
International Maritime Illness or Death Investigation	0920-0821	Attachment A Maritime investigation form
Land Travel Illness or Death Investigation	none	Land Travel Illness or Death Investigation
United States Traveler Health Declaration - ARABIC	None	United States Traveler Health Declaration - Arabic Translation Guide
United States Traveler Health Declaration - ENGLISH	None, None, None	United States Traveler Health Declaration - English/Hard Copy ,   United States Traveler Health Declaration - English/Portal ,   United States Health Declaration - English/PDF
United States Traveler Health Declaration - FRENCH	None	United States Traveler Health Declaration - French Translation Guide

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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	1,129,429	3,858	0	1,125,571	0	0
Annual Time Burden (Hours)	85,382	319	0	85,063	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Revision to 0920-0821 requests addition of tools to collect contact information for and assess the risk for Ebola in travelers coming to the United States from certain countries, as well as the addition of tools to assist in active monitoring of these travelers after they arrive in the United States.

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Annual Cost to Federal Government: $31,101,851

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

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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: 02/11/2015

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