OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

2014011-XXX Ebola_Liberia

IC 212266 under ICR 201507-0920-005 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2014011-XXX Ebola_Liberia	Form
Case Report Form Appendix 1--CASE REPORT FORM.pdf	Form
Contact Listing Form Appendix 2--CONTACT LISTING FORM.pdf	Form
2014011-XXX_Ebola_Liberia Request.pdf Letter of Invitation	IC Document
2014011-XXX_Ebola_Liberia.docx Request for Approval	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

2014011-XXX Ebola_Liberia

Agency IC Tracking Number:

0920-14ANY

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Case Report Form	Appendix 1--CASE REPORT FORM.pdf		No		Paper Only
Form	none	Contact Listing Form	Appendix 2--CONTACT LISTING FORM.pdf		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemic Investigation Case Records HHS/CDC

FR Citation: 51 FR 42466

Number of Respondents: 2,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	2,600	0	0	0	0	2,600
Annual IC Time Burden (Hours)	350	0	0	0	0	350
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Invitation	2014011-XXX_Ebola_Liberia Request.pdf	07/08/2014
Request for Approval	2014011-XXX_Ebola_Liberia.docx	07/08/2014

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