Information Collection

Form1a Screening and Enrollment

IC 216245 under ICR 201504-0925-005 · OMB 0925-0715.

Documents and Forms

Document Name Document Type
Form 1a Form1a Screening and Enrollment Form and Instruction
1a Screening and Enrollment Attachment 7 - Form1a Screening and Enrollment Log.pdf Form and Instruction
2a Eligibility Checklist Attachment 8 -Form2a Eligibility Checklist.pdf Form and Instruction
3a Subject Identification Attachment 9 -Form3a Subject Identification.pdf Form and Instruction
4a Demographic and Exposure Information Attachment 10 -Form4a Demographic and Exposure Information.pdf Form and Instruction
5a Current Symptoms Attachment 11 -Form5a Current Symptoms.pdf Form and Instruction
6a Medical History Attachment 12 -Form6a Medical History.pdf Form and Instruction
7a Enrollment Specimen Collection Attachment 13 -Form7a Enrollment Specimen Collection.pdf Form and Instruction
8a Follow Up Assessment Attachment 14 -Form8a Follow Up Assessment.pdf Form and Instruction
9a ED Chart Review Attachment 15 -Form9a ED Chart Review.pdf Form and Instruction
10a Chart Review - Inpatient Hospitalization Attachment 16 -Form10a Chart Review - Inpatient Hospitalization.pdf Form and Instruction
11a Subject Withdrawl Form Attachment 17 -Form11a Subject Withdrawal Form.pdf Form and Instruction
12a Subject Checklist Attachment 18 -Form12a Subject Checklist.pdf Form and Instruction
13a Enrollment Report Attachment 19 -Form13a Enrollment Report.pdf Form and Instruction
14a 10% Data Accuracy Report Attachment 20 -Form14a 10% Data Accuracy Report.pdf Form and Instruction
15a QC Checklist Attachment 21 -Form15a QC Checklist.pdf Form and Instruction
Attachment 3_IRB approved IFC_Test.pdf Attachment 3 IRB approved IFC Test IC Document
Attachment 4_Informed Consent Influenza Test_CGMH.docx Attachment 4 Informed Consent Influenza IC Document
Attachment 5_IRB approved IFC_Positive.pdf Attachment 5 IRB approved IFC Positive IC Document
Attachment 6_Informed Consent Positive_CGMH.docx Attachment 6 Informed Consent Positive_CGMH IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Form1a Screening and Enrollment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1a	Screening and Enrollment	Attachment 7 - Form1a Screening and Enrollment Log.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2a	Eligibility Checklist	Attachment 8 -Form2a Eligibility Checklist.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	3a	Subject Identification	Attachment 9 -Form3a Subject Identification.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	4a	Demographic and Exposure Information	Attachment 10 -Form4a Demographic and Exposure Information.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	5a	Current Symptoms	Attachment 11 -Form5a Current Symptoms.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	6a	Medical History	Attachment 12 -Form6a Medical History.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	7a	Enrollment Specimen Collection	Attachment 13 -Form7a Enrollment Specimen Collection.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	8a	Follow Up Assessment	Attachment 14 -Form8a Follow Up Assessment.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	9a	ED Chart Review	Attachment 15 -Form9a ED Chart Review.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	10a	Chart Review - Inpatient Hospitalization	Attachment 16 -Form10a Chart Review - Inpatient Hospitalization.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	11a	Subject Withdrawl Form	Attachment 17 -Form11a Subject Withdrawal Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	12a	Subject Checklist	Attachment 18 -Form12a Subject Checklist.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	13a	Enrollment Report	Attachment 19 -Form13a Enrollment Report.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	14a	10% Data Accuracy Report	Attachment 20 -Form14a 10% Data Accuracy Report.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	15a	QC Checklist	Attachment 21 -Form15a QC Checklist.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	1,500	1,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 3 IRB approved IFC Test	Attachment 3_IRB approved IFC_Test.pdf	04/22/2015
Attachment 4 Informed Consent Influenza	Attachment 4_Informed Consent Influenza Test_CGMH.docx	04/22/2015
Attachment 5 IRB approved IFC Positive	Attachment 5_IRB approved IFC_Positive.pdf	04/22/2015
Attachment 6 Informed Consent Positive_CGMH	Attachment 6_Informed Consent Positive_CGMH.docx	04/22/2015

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