Information Collection

Undetermined risk factors for ocular syphilis - North Carolina, 2015

IC 219234 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⚠️ Notice: This information collection may be referencing outdated material.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
Undetermined risk factors for ocular syphilis - North Carolina, 2015	Form
Abstraction Form Appendix 1. Abstraction Form.docx	Form
Interview Form Appendix 2. Interview Form.docx	Form
0920-1011 GenIC Request 2016006-XXX Ocular Syphilis_NC.msg Burden Estimat - Email	IC Document
Letter of Invitation.pdf Letter of Invitation	IC Document
2016006-XXX_Ocular Syphilis.docx 0920-1011 GenIC Request	IC Document

IC Title:

Undetermined risk factors for ocular syphilis - North Carolina, 2015

Agency IC Tracking Number:

16GY

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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	NA	Abstraction Form	Appendix 1. Abstraction Form.docx	NA	No		Paper Only
Form	NA	Interview Form	Appendix 2. Interview Form.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0113 Epidemic Investigation Case Records

FR Citation: 51 FR 42466

Number of Respondents: 55

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	88	88
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Burden Estimat - Email	0920-1011 GenIC Request 2016006-XXX Ocular Syphilis_NC.msg	12/09/2015
Letter of Invitation	Letter of Invitation.pdf	12/09/2015
0920-1011 GenIC Request	2016006-XXX_Ocular Syphilis.docx	12/09/2015

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