Surveillance Data Collections for Ebola Virus Disease in West Africa

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Health Facility Assessment and Case Finding Study - Arabic	Form and Instruction	New	Available
Health Facility Assessment and Case Finding Study - Portuguese	Form and Instruction	New	Available
Health Facility Assessment and Case Finding Study - French	Form and Instruction	New	Available
Health Facility Assessment and Case Finding Study - English	Form and Instruction	New	Available
Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone	Form and Instruction	New	Available
Health Care Worker Ebola Virus Investigation Questionnaire - Liberia	Form and Instruction	New	Available
Health Care Worker EVD Exposure Risk - Arabic	Form	New	Available
Health Care Worker EVD Exposure Risk - Portuguese	Form	New	Available
Health Care Worker EVD Exposure Risk - French	Form	New	Available
Health Care Worker EVD Exposure Risk - English	Form	New	Available
Ebola Sexual Transmission Investigation Form - Arabic	Form and Instruction	New	Available
Ebola Sexual Transmission Investigation Form - Portuguese	Form and Instruction	New	Available
Ebola Sexual Transmission Investigation Form - French	Form and Instruction	New	Available
Ebola Sexual Transmission Investigation Form - English	Form and Instruction	New	Available
EVD Case Contact Questionnaire - Arabic	Form and Instruction	New	Available
EVD Case Contact Questionnaire - Portuguese	Form and Instruction	New	Available
EVD Case Contact Questionnaire - French	Form and Instruction	New	Available
EVD Case Contact Questionnaire - English	Form and Instruction	New	Available
VHF Contact Tracing Follow-Up Form - Arabic	Form	New	Available
VHF Contact Tracing Follow-Up Form - Portuguese	Form	New	Available
VHF Contact Tracing Follow-Up Form - French	Form	New	Available
VHF Contact Tracing Follow-Up Form - English	Form	New	Available
VHF Contact Listing Form - Arabic	Form	New	Available
VHF Contact Listing Form - Portuguese	Form	New	Available
VHF Contact Listing Form - French	Form	New	Repair queued
VHF Contact Listing Form - English	Form	New	Available
VHF Case Investigation Form - Arabic	Form and Instruction	New	Available
VHF Case Investigation Form - Portuguese	Form and Instruction	New	Available
VHF Case Investigation Form - French	Form and Instruction	New	Available
VHF Case Investigation Form - English	Form and Instruction	New	Available
VHF Case Investigation (Short Form) - Arabic	Form and Instruction	New	Available
VHF Case Investigation (Short Form) - Portuguese	Form and Instruction	New	Available
VHF Case Investigation (Short Form) - French	Form and Instruction	New	Available
VHF Case Investigation (Short Form) - English	Form and Instruction	New	Available
SupStmnt A Survllnc Data Collctn EVD West Africa 20150621.docx	Supporting Statement A	Uploaded 2015-06-30	Available
AppndxD West Africa Defn Burden Wage Est 20150621.docx	Supplementary Document	Uploaded 2015-06-29	Available
AppndxC EVDOutbrksChronology.pdf	Supplementary Document	Uploaded 2015-06-29	Available
AppndxC 2014 EVDGeoDistrbtn.pdf	Supplementary Document	Uploaded 2015-06-29	Available
AppndxB 60 day FRN 20150327.pdf	Supplementary Document	Uploaded 2015-06-29	Repair queued
AppndxA Auth Legisltn 42 CFR 241.pdf	Supplementary Document	Uploaded 2015-06-29	Available
SupStmnt B Survllnc Data Collctn EVD West Africa 20150621.docx	Supporting Statement B	Uploaded 2015-06-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217290	Health Facility Assessment and Case Finding Study - Arabic	Form and Instruction	New
217289	Health Facility Assessment and Case Finding Study - Portuguese	Form and Instruction	New
217288	Health Facility Assessment and Case Finding Study - French	Form and Instruction	New
217287	Health Facility Assessment and Case Finding Study - English	Form and Instruction	New
217286	Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone	Form and Instruction	New
217285	Health Care Worker Ebola Virus Investigation Questionnaire - Liberia	Form and Instruction	New
217283	Health Care Worker EVD Exposure Risk - Arabic	Form	New
217282	Health Care Worker EVD Exposure Risk - Portuguese	Form	New
217281	Health Care Worker EVD Exposure Risk - French	Form	New
217280	Health Care Worker EVD Exposure Risk - English	Form	New
217279	Ebola Sexual Transmission Investigation Form - Arabic	Form and Instruction	New
217278	Ebola Sexual Transmission Investigation Form - Portuguese	Form and Instruction	New
217277	Ebola Sexual Transmission Investigation Form - French	Form and Instruction	New
217276	Ebola Sexual Transmission Investigation Form - English	Form and Instruction	New
217275	EVD Case Contact Questionnaire - Arabic	Form and Instruction	New
217274	EVD Case Contact Questionnaire - Portuguese	Form and Instruction	New
217273	EVD Case Contact Questionnaire - French	Form and Instruction	New
217272	EVD Case Contact Questionnaire - English	Form and Instruction	New
217270	VHF Contact Tracing Follow-Up Form - Arabic	Form	New
217269	VHF Contact Tracing Follow-Up Form - Portuguese	Form	New
217268	VHF Contact Tracing Follow-Up Form - French	Form	New
217263	VHF Contact Tracing Follow-Up Form - English	Form	New
217262	VHF Contact Listing Form - Arabic	Form	New
217261	VHF Contact Listing Form - Portuguese	Form	New
217260	VHF Contact Listing Form - French	Form	New
217259	VHF Contact Listing Form - English	Form	New
217253	VHF Case Investigation Form - Arabic	Form and Instruction	New
217252	VHF Case Investigation Form - Portuguese	Form and Instruction	New
217251	VHF Case Investigation Form - French	Form and Instruction	New
217250	VHF Case Investigation Form - English	Form and Instruction	New
217249	VHF Case Investigation (Short Form) - Arabic	Form and Instruction	New
217247	VHF Case Investigation (Short Form) - Portuguese	Form and Instruction	New
217246	VHF Case Investigation (Short Form) - French	Form and Instruction	New
217245	VHF Case Investigation (Short Form) - English	Form and Instruction	New

ICR Details

OMB Control No: 0920-1085	ICR Reference No: 201505-0920-008
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15UX
Title: Surveillance Data Collections for Ebola Virus Disease in West Africa
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/14/2015
	Date Received in OIRA: 07/13/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2018	36 Months From Approved
Responses	946,500	0	0
Time Burden (Hours)	428,757	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This is a request for a new OMB package that includes all of the forms for the International data collection for the Ebola virus disease response from 2014. This ICR will allow CDC to continue Ebola-related information collections beyond their current emergency expiration dates and to conduct newly proposed information collections within international borders of Ebola-affected countries.

---

Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 16405	03/27/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 36994	06/29/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 34

table that charts list of burden

IC Title	Form No.	Form Name
Ebola Sexual Transmission Investigation Form - English	None	Ebola Sexual Transmission Investigation Form - English
Ebola Sexual Transmission Investigation Form - French	None	Ebola Sexual Transmission Investigation Form - French
Ebola Sexual Transmission Investigation Form - Portuguese	None	Ebola Sexual Transmission Investigation Form - Portuguese
Ebola Sexual Transmission Investigation Form - Arabic	None	Ebola Sexual Transmission Investigation Form - Arabic
Health Care Worker EVD Exposure Risk - English	None	Health Care Worker EVD Exposure Risk - English
Health Care Worker EVD Exposure Risk - French	None	Health Care Worker EVD Exposure Risk - French
Health Care Worker EVD Exposure Risk - Portuguese	None	Health Care Worker EVD Exposure Risk - Portuguese
Health Care Worker EVD Exposure Risk - Arabic	None	Health Care Worker EVD Exposure Risk - Arabic
Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone	None	Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone
Health Facility Assessment and Case Finding Study - English	None	Health Facility Assessment and Case Finding Study - English
Health Facility Assessment and Case Finding Study - French	None	Health Facility Assessment and Case Finding Study - French
Health Facility Assessment and Case Finding Study - Portuguese	None	Health Facility Assessment and Case Finding Study - Portuguese
Health Facility Assessment and Case Finding Study - Arabic	None	Health Facility Assessment and Case Finding Study - Arabic
VHF Case Investigation (Short Form) - English	None	VHF Case Investigation (Short Form) - English
VHF Case Investigation (Short Form) - French	None	VHF Case Investigation (Short Form) - French
VHF Case Investigation (Short Form) - Portuguese	None	VHF Case Investigation (Short Form) - Portuguese
VHF Case Investigation Form - French	None	VHF Case Investigation Form - French
VHF Contact Listing Form - English	None	VHF Contact Listing Form - English
VHF Contact Listing Form - French	None	VHF Contact Listing Form - French
VHF Contact Listing Form - Arabic	None	VHF Contact Listing Form - Arabic
VHF Contact Tracing Follow-Up Form - English	None	VHF Contact Tracing Follow-Up Form - English
Health Care Worker Ebola Virus Investigation Questionnaire - Liberia	None	Health Care Worker Ebola Virus Investigation Questionnaire - Liberia
VHF Case Investigation (Short Form) - Arabic	None	VHF Case Investigation (Short Form) - Arabic
VHF Case Investigation Form - English	None	VHF Case Investigation Form - English
VHF Case Investigation Form - Portuguese	None	VHF Case Investigation Form - Portuguese
VHF Case Investigation Form - Arabic	None	VHF Case Investigation Form - Arabic
VHF Contact Tracing Follow-Up Form - French	None	VHF Contact Tracing Follow-Up Form - French
VHF Contact Listing Form - Portuguese	None	VHF Contact Listing Form - Portuguese
VHF Contact Tracing Follow-Up Form - Portuguese	None	VHF Contact Tracing Follow-Up Form - Portuguese
VHF Contact Tracing Follow-Up Form - Arabic	None	VHF Contact Tracing Follow-Up Form - Arabic
EVD Case Contact Questionnaire - English	None	EVD Case Contact Questionnaire - English
EVD Case Contact Questionnaire - French	None	EVD Case Contact Questionnaire - French
EVD Case Contact Questionnaire - Portuguese	None	EVD Case Contact Questionnaire - Portuguese
EVD Case Contact Questionnaire - Arabic	None	EVD Case Contact Questionnaire - Arabic

---

ICR Summary of Burden

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	946,500	0	0	946,500	0	0
Annual Time Burden (Hours)	428,757	0	0	428,757	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Submission of 0920-15UX is a New ICR and contains an increase in Burden Hours.

---

Annual Cost to Federal Government: $3,707,498

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/13/2015

---