Contact investigation Outcome Reporting Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Script for DGMQ HotLine - Introduction	Form and Instruction	New	Available
Ebola Exposure Questionnaire for Passengers on Other Commercial Conveyances	Form and Instruction	New	Available
Ebola Exposure Questionnaire for Airport Staff	Form and Instruction	New	Available
Ebola Exposure Questionnaire for Cleaning Crew	Form and Instruction	New	Available
Ebola Exposure Questionnaire for Flight Crew	Form and Instruction	New	Available
Ebola Exposure Questionnaire for Airline Passengers	Form and Instruction	New	Available
Ebola Airline Exposure Assessment Passenger	Form	Removed	Available
Ebola Airline Exposure Assessment Airport or other Staff	Form	Removed	Available
Ebola Airline Exposure Assessment Cleaning Staff	Form	Removed	Available
Ebola Airline Exposure Assessment Flight Crew	Form	Removed	Available
Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged	Available
State/Local Rubella Outcome Reporting (Air)	Form	Unchanged	Available
Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged	Available
State/Local Measles Outcome Reporting (Air)	Form	Unchanged	Available
Cruise Ship TB Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged	Available
State/Local TB Outcoming Reporting (Air)	Form	Unchanged	Available
State/Local General Outcome Reporting (Land)	Form	Unchanged	Available
Cruise Ship General Outcome Reporting -Maritime (Word & Excel)	Form	Unchanged	Available
State/Local General Outcome Reporting (Air)	Form	Unchanged	Available
Attachment B 60 Day FRN 0920-0900 Revision.pdf	Supplementary Document	Uploaded 2015-02-17	Available
Attachment A3 42 CFR part 71.pdf	Supplementary Document	Uploaded 2015-02-17	Available
Attachment A2 42 CFR part 70.pdf	Supplementary Document	Uploaded 2015-02-17	Available
Attachment A1 Section 361 of the Public Health Service Act (42 USC 264).....pdf	Supplementary Document	Uploaded 2015-02-17	Available
0920-0900 Supporting Statement B - 1302015.docx	Supporting Statement B	Uploaded 2015-02-17	Available
0920-0900 Supporting Statement A - 6162015.docx	Supporting Statement A	Uploaded 2015-06-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
215026	Script for DGMQ HotLine - Introduction	Form and Instruction	New
215025	Ebola Exposure Questionnaire for Passengers on Other Commercial Conveyances	Form and Instruction	New
215024	Ebola Exposure Questionnaire for Airport Staff	Form and Instruction	New
215020	Ebola Exposure Questionnaire for Cleaning Crew	Form and Instruction	New
215018	Ebola Exposure Questionnaire for Flight Crew	Form and Instruction	New
215017	Ebola Exposure Questionnaire for Airline Passengers	Form and Instruction	New
213429	Ebola Airline Exposure Assessment Passenger	Form	Removed
213428	Ebola Airline Exposure Assessment Airport or other Staff	Form	Removed
213427	Ebola Airline Exposure Assessment Cleaning Staff	Form	Removed
213426	Ebola Airline Exposure Assessment Flight Crew	Form	Removed
212223	Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged
212222	State/Local Rubella Outcome Reporting (Air)	Form	Unchanged
212221	Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged
197948	State/Local Measles Outcome Reporting (Air)	Form	Unchanged
197947	Cruise Ship TB Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged
197946	State/Local TB Outcoming Reporting (Air)	Form	Unchanged
197945	State/Local General Outcome Reporting (Land)	Form	Unchanged
197944	Cruise Ship General Outcome Reporting -Maritime (Word & Excel)	Form	Unchanged
197943	State/Local General Outcome Reporting (Air)	Form	Unchanged

ICR Details

OMB Control No: 0920-0900	ICR Reference No: 201502-0920-008
Status: Historical Active	Previous ICR Reference No: 201407-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Contact investigation Outcome Reporting Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/22/2015
	Date Received in OIRA: 03/03/2015
Terms of Clearance: When the Ebola outbreak ends, CDC should submit a change request to remove those forms from this ICR. Addtionally, in the context of an emergency response, like forms for additional diseases may be added as non-substantive changes.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2018	36 Months From Approved	10/31/2017
Responses	6,457	0	4,577
Time Burden (Hours)	783	0	783
Cost Burden (Dollars)	0	0	0

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Abstract: Section 361 of the Public Health Service Act (42 USC 264) authorizes the Secretary of Health and Human Services to make and enforce regulations necessary to prevent the introduction, transmission or spread of communicable diseases from foreign countries into the United States. This is a request to revise the data collection forms after extensive review. The package includes forms for contact investigations of individuals who may have come into contact with travelers that are confirmed to have Ebola infection.

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Authorizing Statute(s): US Code: 42 USC 264 Name of Law: The Public Health and Welfare
   US Code: 42 USC 70-71 Name of Law: Quarantine, Inspection, Licensing
  

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 74099	12/15/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 9725	02/24/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Ebola Exposure Questionnaire for Passengers on Other Commercial Conveyances	None	Ebola Exposure Questionnaire for Passengers of Other Commercial Conveyances
Script for DGMQ HotLine - Introduction	None	Script for DGMQ HotLine - Introduction, Flight and Seat Confirmation Ebola Air Contact Investigation
Ebola Exposure Questionnaire for Airport Staff	None	Ebola Exposure Questionnaire for Airport Staff
Cruise Ship TB Outcome Reporting - Maritime (Word & Excel)	none, none	TB Maritime Word ,   TB Maritime (Excel)
State/Local Measles Outcome Reporting (Air)	none	Measles (Air)
Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel)	none, none	Measles Maritime (Word) ,   Measles Maritime (Excel)
State/Local Rubella Outcome Reporting (Air)	none	Rubella (Air)
Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel)	none, none	Rubella Maritime (Excel) ,   Rubella Maritime (Word)
Ebola Airline Exposure Assessment Cleaning Staff	none	Ebola Airline Exposure Assessment Cleaning Staff
Ebola Exposure Questionnaire for Flight Crew	None	Ebola Exposure Questionnaire for Flight Crew
State/Local General Outcome Reporting (Air)	none	General Contact Investigation - Air
Cruise Ship General Outcome Reporting -Maritime (Word & Excel)	none, none	General Reporting Maritime (Excel) ,   General Reporting Maritime (Word)
State/Local General Outcome Reporting (Land)	none	General Contact Reporting (Land)
State/Local TB Outcoming Reporting (Air)	none	TB Reporting (Air)
Ebola Airline Exposure Assessment Flight Crew	none	Ebola Airline Exposure Assessment Flight Crew
Ebola Airline Exposure Assessment Airport or other Staff	none	Ebola Airline Exposure Assessment Airport or Other Staff
Ebola Airline Exposure Assessment Passenger	none	Ebola Airline Exposure Assessment Passenger
Ebola Exposure Questionnaire for Airline Passengers	None	Ebola Exposure Questionnaire for Airline Passengers
Ebola Exposure Questionnaire for Cleaning Crew	None	Ebola Exposure Questionnaire for Cleaninig Crew

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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	6,457	4,577	0	1,880	0	0
Annual Time Burden (Hours)	783	783	0	0	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: ICR Revision for 0920-0900 contains addition of Ebola Questionnaires as well as additional forms.

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Annual Cost to Federal Government: $1,349,465

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: 03/03/2015

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