Information Collection

Form1a Screening and Enrollment

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

Documents and Forms

Documents and forms in this information collection
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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.