Information Collection

Pediatric cluster of neurologic symptoms - Colorado

IC 213189 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⚠️ Notice: This information collection may be referencing outdated material.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
Pediatric cluster of neurologic symptoms - Colorado	Form
Medical Chart Abstraction 2014018-XXX_Appendix 1.docx	Form
Family Interview Questionnaire 2014018-XXX_Appendix 2.docx	Form
2014018-XXX_Pediatric_CO.docx Application	IC Document
CO letter of invitation.msg Letter of Invitation	IC Document

IC Title:

Pediatric cluster of neurologic symptoms - Colorado

Agency IC Tracking Number:

14AZI

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301

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	Medical Chart Abstraction	2014018-XXX_Appendix 1.docx		Yes	Yes	Fillable Fileable
Form	none	Family Interview Questionnaire	2014018-XXX_Appendix 2.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18

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	Previously Approved
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Application	2014018-XXX_Pediatric_CO.docx	09/22/2014
Letter of Invitation	CO letter of invitation.msg	09/22/2014

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