Case Report Form for Coccidioidomycosis

Enhanced Surveillance of Coccidioidomycosis in Low- and Non-Endemic States

Documents and Forms

Document Name Document Type
Case Report Form for Coccidioidomycosis Form
Case Report for Coccidioidomycosis Attachment 4 CRF for cocci enhanced surveillance 4.15.15.docx Form

Information Collection (IC) Details

IC Title:	Case Report Form for Coccidioidomycosis	Agency IC Tracking Number:	15UR

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Case Report for Coccidioidomycosis	Attachment 4 CRF for cocci enhanced surveillance 4.15.15.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 145	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	145	145
Annual IC Time Burden (Hours)	48	48
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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