National Disease Surveillance Program III – CDC Support for Case Investigation, Contact Tracing, and Case Reports

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
White Evening Report	Form and Instruction	New	Available
Symptom Monitoring Form - Environmental Services Personnel	Form and Instruction	New	Repair queued
EVD Tracking Form - Environmental Services Personnel	Form and Instruction	New	Repair queued
Symptom Monitoring Form - Laboratory Personnel	Form and Instruction	New	Repair queued
EVD Tracking Form - Laboratory Personnel	Form and Instruction	New	Repair queued
Symptom Monitoring Form - HCW	Form and Instruction	New	Repair queued
EVD Tracking Form for Health Care Workers	Form and Instruction	New	Repair queued
Symptom Monitoring Form - Contact	Form and Instruction	New	Repair queued
EVD Contact Tracing Form - United States	Form and Instruction	New	Available
Symptom Monitoring Form - PUI	Form and Instruction	New	Repair queued
EVD Person Under Investigation (PUI) Form	Form and Instruction	New	Available
Symptom Monitoring Form - General Public	Form and Instruction	New	Repair queued
Ebola Virus Disease Case Investigation Form – United States	Form and Instruction	New	Available
Att11 Generic End-of-Monitoring Letter.docx	Supplementary Document	Uploaded 2015-07-20	Repair queued
Att10b Info for HCWs Treating Ebola Patients 20150123.docx	Supplementary Document	Uploaded 2015-07-20	Repair queued
Att10a Guidance for Contacts of Ebola Patients.docx	Supplementary Document	Uploaded 2015-07-20	Repair queued
Att9c Guidnce Eval Triage of Ebola Contacts 20150123.docx	Supplementary Document	Uploaded 2015-07-20	Repair queued
Att9b Guid HD Tracing Commnity Contacts.docx	Supplementary Document	Uploaded 2015-07-20	Available
Att9a Guidance for HD DA-AM Retrnd Travlrs 20150123.docx	Supplementary Document	Uploaded 2015-07-20	Available
AppndxE NNDSS Core Data Element Requirements 0920-0728.xlsx	Supplementary Document	Uploaded 2015-07-16	Available
AppndxD. CSTENotifiableConditionListA.pdf	Supplementary Document	Uploaded 2015-07-16	Repair queued
AppndxC Domestic Defn Burd.docx	Supplementary Document	Uploaded 2015-07-16	Repair queued
AppndxA Auth Legisltn 42 CFR 241.pdf	Supplementary Document	Uploaded 2015-07-16	Repair queued
App B 60 day published.pdf	Supplementary Document	Uploaded 2015-07-16	Repair queued
SupStmnt B Domestic surveillance.docx	Supporting Statement B	Uploaded 2015-07-16	Available
SupStmnt A Domestic surveillance clean.docx	Supporting Statement A	Uploaded 2015-07-16	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217553	White Evening Report	Form and Instruction	New
217552	Symptom Monitoring Form - Environmental Services Personnel	Form and Instruction	New
217551	EVD Tracking Form - Environmental Services Personnel	Form and Instruction	New
217550	Symptom Monitoring Form - Laboratory Personnel	Form and Instruction	New
217549	EVD Tracking Form - Laboratory Personnel	Form and Instruction	New
217548	Symptom Monitoring Form - HCW	Form and Instruction	New
217547	EVD Tracking Form for Health Care Workers	Form and Instruction	New
217546	Symptom Monitoring Form - Contact	Form and Instruction	New
217545	EVD Contact Tracing Form - United States	Form and Instruction	New
217544	Symptom Monitoring Form - PUI	Form and Instruction	New
217543	EVD Person Under Investigation (PUI) Form	Form and Instruction	New
217513	Symptom Monitoring Form - General Public	Form and Instruction	New
217506	Ebola Virus Disease Case Investigation Form – United States	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 201507-0920-004
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15VA
Title: National Disease Surveillance Program III – CDC Support for Case Investigation, Contact Tracing, and Case Reports
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: Withdrawn	Conclusion Date: 12/10/2015
	Date Received in OIRA: 07/21/2015
Terms of Clearance: After phone discussion with CDC 12/10/2015, this ICR will be withdrawn and re-submitted as a broader generic umbrella.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection is designed to continue CDC assistance in establishing and supporting active surveillance systems for Ebola Virus Disease (EVD) for STL authorities in the US. Because EVD remains a public health emergency and may re-emerge in the future, establishing these long-term ICRs will greatly reduce administrative processing for PRA clearance and CDC staff can more quickly assist authorities in their own jurisdictions, and extend the CDC's ability to conduct active case and contact investigations of immediate national notifiable conditions when assistance is requested by STL authorities.

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

Citations for New Statutory Requirements: None

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

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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 42500	07/17/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 13

table that charts list of burden

IC Title	Form No.	Form Name
Symptom Monitoring Form - Laboratory Personnel	NA	Symptom Monitoring Form
EVD Tracking Form - Environmental Services Personnel	NA	Contact Tracing Form for Environmental Workers for Ebola patients
Ebola Virus Disease Case Investigation Form – United States	NA	Ebola Virus Disease Case Investigation Form – United States
Symptom Monitoring Form - General Public	NA	Symptom Monitoring Form
EVD Person Under Investigation (PUI) Form	NA	Person Under Investigation (PUI) for Ebola Form - United States
Symptom Monitoring Form - PUI	NA	Symptom Monitoring Form
Symptom Monitoring Form - Contact	NA	Symptom Monitoring Form
Symptom Monitoring Form - HCW	NA	Symptom Monitoring Form
EVD Tracking Form - Laboratory Personnel	NA	Contact Tracing Form for Laboratory Workers handling specimens from Ebola patients
EVD Contact Tracing Form - United States	NA	EVD Contact Tracing Form - United States
EVD Tracking Form for Health Care Workers	NA	Contact Tracing Form for HCW caring for Ebola patients
Symptom Monitoring Form - Environmental Services Personnel	NA	Symptom Monitoring Form
White Evening Report	NA	Daily White House Report

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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: 0920-15VA submission is a New ICR.

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Annual Cost to Federal Government: $414,408

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

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Common Form ICR:  No

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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: 07/21/2015

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