Information Collection

Adverse Health Effects Associated with Synthetic Cannabinoid Use - Mississippi, 2015

IC 216276 under ICR 201502-0920-018 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adverse Health Effects Associated with Synthetic Cannabinoid Use - Mississippi, 2015	Form
Synthetic Cannabinoid Use - Medical Records Abstraction Appendix1_medical abstraction form.docx	Form
Synthetic Cannabinoid Use - Patient (or Surrogate) Inter Appendix2_Patient Interview Questionnaire.docx	Form
0920-1011 Marijuana_MS.docx Request for GenIC Approval	IC Document
MS_Epi AID Request 4 23 15.pdf MS Epi-Aid Request - LOI	IC Document
FW URGENT 0920-1011 GenIC Request 2015007-XXX Marijuana_MS.msg Urgent GenIC Request - email w/ Burden Table	IC Document

IC Title:

Adverse Health Effects Associated with Synthetic Cannabinoid Use - Mississippi, 2015

Agency IC Tracking Number:

0920-1011

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	None	Synthetic Cannabinoid Use - Medical Records Abstraction Form	Appendix1_medical abstraction form.docx	None	No		Paper Only
Form	None	Synthetic Cannabinoid Use - Patient (or Surrogate) Interview	Appendix2_Patient Interview Questionnaire.docx	None	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemic Investigation Case Records

FR Citation: 51 FR 4246

Number of Respondents: 430

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	430	430
Annual IC Time Burden (Hours)	426	426
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for GenIC Approval	0920-1011 Marijuana_MS.docx	04/24/2015
MS Epi-Aid Request - LOI	MS_Epi AID Request 4 23 15.pdf	04/24/2015
Urgent GenIC Request - email w/ Burden Table	FW URGENT 0920-1011 GenIC Request 2015007-XXX Marijuana_MS.msg	04/24/2015

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