Information Collection

Bsi_ca

IC 213101 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⚠️ Notice: This information collection may be referencing outdated material.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
BSI_CA	Form
Chart Abstraction Chart Abstraction Form.doc	Form
Outpatient Dialysis Practices Survey Outpatient Dialysis Center Practices Survey.docx	Form
Reprocessing Observation Checklist Reprocessing Observation Checklist.docx	Form
Letter of Invite.docx Letter of Invitation	IC Document
2014017_XXX_BSI_CA.docx Supporting Statement	IC Document

IC Title:

BSI_CA

Agency IC Tracking Number:

14AYU

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR USC 301 [241] (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	Available Electronically?	Electronic Capability
Form	none	Chart Abstraction	Chart Abstraction Form.doc	No	Paper Only
Form	none	Outpatient Dialysis Practices Survey	Outpatient Dialysis Center Practices Survey.docx	No	Paper Only
Form	none	Reprocessing Observation Checklist	Reprocessing Observation Checklist.docx	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

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

FR Citation: 51 FR 42466

Number of Respondents: 26

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	26	26
Annual IC Time Burden (Hours)	85	85
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Invitation	Letter of Invite.docx	09/12/2014
Supporting Statement	2014017_XXX_BSI_CA.docx	09/15/2014

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