OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

2014008-XXX Chikungunya_PR

IC 211951 under ICR 201511-0920-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
2014008-XXX Chikungunya_PR	Form
Household Questionnaire Appendix 1 - Household questionnaire.pdf	Form
Individual Questionnaire Appendix 2 - Individual quesionnaire.pdf	Form
Case Report (English) Appendix 3a - Case Reporting Form [English].pdf	Form
Case Report (Spanish) Appendix 3b - Spanish Case reporting form.pdf	Form
Request for Approval Chikungunya_PR.docx Request for Approval	IC Document
Letter of Invitation Chikungunya_PR.pdf Letter of Invitation	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

2014008-XXX Chikungunya_PR

Agency IC Tracking Number:

0920-14AJK

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR Public Health Service Act (To search for a specific CFR, visit the Code of Federal Regulations.)

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	Household Questionnaire	Appendix 1 - Household questionnaire.pdf		No		Paper Only
Form	none	Individual Questionnaire	Appendix 2 - Individual quesionnaire.pdf		No		Paper Only
Form	none	Case Report (English)	Appendix 3a - Case Reporting Form [English].pdf		No		Paper Only
Form	none	Case Report (Spanish)	Appendix 3b - Spanish Case reporting form.pdf		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0113 Epidemic Investigation Case Records HHS/CDC

FR Citation: 51 FR 42466

Number of Respondents: 6,256

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	6,256	0	0	0	0	6,256
Annual IC Time Burden (Hours)	1,564	0	0	0	0	1,564
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval	Request for Approval Chikungunya_PR.docx	06/18/2014
Letter of Invitation	Letter of Invitation Chikungunya_PR.pdf	06/18/2014

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