US/WHO International Clinical Network Ebola Virus Disease Clinical Data Collection Tool

Data Supplement for Ebola Virus Disease Patients Treated Outside of West Africa

Documents and Forms

Document Name Document Type
US/WHO International Clinical Network Ebola Virus Disease Clinical Data Collection Tool Form
US/WHO Clinical Network EVD Data Collection Tool AppndxC US-WHO ClinNetworkEVDDataCollTool 20150604.xlsx Form

Information Collection (IC) Details

IC Title:	US/WHO International Clinical Network Ebola Virus Disease Clinical Data Collection Tool	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	None	US/WHO Clinical Network EVD Data Collection Tool	AppndxC US-WHO ClinNetworkEVDDataCollTool 20150604.xlsx	None	Yes	Yes	Fillable Fileable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records
Title: Epidemic Investigation Case Records	FR Citation: 51 FR 42466

Number of Respondents: 21	Number of Respondents for Small Entity: 18

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	32	32
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.