Information Collection Request

Contact investigation Outcome Reporting Forms

ICR 201502-0920-008 · OMB 0920-0900 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Script for DGMQ HotLine - Introduction, Flight and Seat Confirmation Ebola Air Contact Investigation Form and Instruction New Available
Ebola Exposure Questionnaire for Passengers of Other Commercial Conveyances Form and Instruction New Available
Ebola Exposure Questionnaire for Airport Staff Form and Instruction New Available
Ebola Exposure Questionnaire for Cleaninig 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
Rubella Maritime (Excel) Form Unchanged Available
Rubella Maritime (Word) Form Unchanged Available
Rubella (Air) Form Unchanged Available
Measles Maritime (Excel) Form Unchanged Available
Measles Maritime (Word) Form Unchanged Available
Measles (Air) Form Unchanged Available
TB Maritime (Excel) Form Unchanged Available
TB Maritime Word Form Unchanged Available
TB Reporting (Air) Form Unchanged Available
General Contact Reporting (Land) Form Unchanged Available
General Reporting Maritime (Word) Form Unchanged Available
General Reporting Maritime (Excel) Form Unchanged Available
General Contact Investigation - 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 IDCollectionTypeStatusForm
215026 Script for DGMQ HotLine - Introduction Form and Instruction NewScript for DGMQ HotLine - Introduction, Flight and Seat Confirmation Ebola Air Contact Investigation
215025 Ebola Exposure Questionnaire for Passengers on Other Commercial Conveyances Form and Instruction NewEbola Exposure Questionnaire for Passengers of Other Commercial Conveyances
215024 Ebola Exposure Questionnaire for Airport Staff Form and Instruction NewEbola Exposure Questionnaire for Airport Staff
215020 Ebola Exposure Questionnaire for Cleaning Crew Form and Instruction NewEbola Exposure Questionnaire for Cleaninig Crew
215018 Ebola Exposure Questionnaire for Flight Crew Form and Instruction NewEbola Exposure Questionnaire for Flight Crew
215017 Ebola Exposure Questionnaire for Airline Passengers Form and Instruction NewEbola Exposure Questionnaire for Airline Passengers
213429 Ebola Airline Exposure Assessment Passenger Form RemovedEbola Airline Exposure Assessment Passenger
213428 Ebola Airline Exposure Assessment Airport or other Staff Form RemovedEbola Airline Exposure Assessment Airport or Other Staff
213427 Ebola Airline Exposure Assessment Cleaning Staff Form RemovedEbola Airline Exposure Assessment Cleaning Staff
213426 Ebola Airline Exposure Assessment Flight Crew Form RemovedEbola Airline Exposure Assessment Flight Crew
212223 Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel) Form UnchangedRubella Maritime (Excel)
212223 Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel) Form UnchangedRubella Maritime (Word)
212222 State/Local Rubella Outcome Reporting (Air) Form UnchangedRubella (Air)
212221 Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel) Form UnchangedMeasles Maritime (Excel)
212221 Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel) Form UnchangedMeasles Maritime (Word)
197948 State/Local Measles Outcome Reporting (Air) Form UnchangedMeasles (Air)
197947 Cruise Ship TB Outcome Reporting - Maritime (Word & Excel) Form UnchangedTB Maritime (Excel)
197947 Cruise Ship TB Outcome Reporting - Maritime (Word & Excel) Form UnchangedTB Maritime Word
197946 State/Local TB Outcoming Reporting (Air) Form UnchangedTB Reporting (Air)
197945 State/Local General Outcome Reporting (Land) Form UnchangedGeneral Contact Reporting (Land)
197944 Cruise Ship General Outcome Reporting -Maritime (Word & Excel) Form UnchangedGeneral Reporting Maritime (Word)
197944 Cruise Ship General Outcome Reporting -Maritime (Word & Excel) Form UnchangedGeneral Reporting Maritime (Excel)
197943 State/Local General Outcome Reporting (Air) Form UnchangedGeneral Contact Investigation - Air

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
06/30/2018 36 Months From Approved 10/31/2017
6,457 0 4,577
783 0 783
0 0 0





Reginfo record details
15
table that charts list of burden
IC Title Form No. Form Name
Cruise Ship General Outcome Reporting -Maritime (Word & Excel) none, none ,  
Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel) none, none ,  
Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel) none, none ,  
Cruise Ship TB Outcome Reporting - Maritime (Word & Excel) none, none ,  
Ebola Airline Exposure Assessment Airport or other Staff none
Ebola Airline Exposure Assessment Cleaning Staff none
Ebola Airline Exposure Assessment Flight Crew none
Ebola Airline Exposure Assessment Passenger none
Ebola Exposure Questionnaire for Airline Passengers None
Ebola Exposure Questionnaire for Airport Staff None
Ebola Exposure Questionnaire for Cleaning Crew None
Ebola Exposure Questionnaire for Flight Crew None
Ebola Exposure Questionnaire for Passengers on Other Commercial Conveyances None
Script for DGMQ HotLine - Introduction None
State/Local General Outcome Reporting (Air) none
State/Local General Outcome Reporting (Land) none
State/Local Measles Outcome Reporting (Air) none
State/Local Rubella Outcome Reporting (Air) none
State/Local TB Outcoming Reporting (Air) none

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


Reginfo record details
  No