Information Collection

EEI Guillain-Barre Syndrome_Bahia Brazil

IC 219577 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⚠️ Notice: This information collection may be referencing outdated material.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
EEI Guillain-Barre Syndrome_Bahia Brazil	Form
Case Control Questionnaire - GBS English Appendix 1a. CaCo questionnaire.doc	Form
Case Control Questionnaire - GBS Portugese Appendix 1b. CaCo questionnaire_Portuguese.doc	Form
Chart Abstraction Questionnaire - GBS English Appendix 2a. Chart abstraction questionnaire.docx	Form
Chart Abstraction Questionnaire - GBS Portugese Appendix 2b. Chart abstraction questionnaire_Portuguese.docx	Form
LOI_CDC Atlanta_signed_Brazil GBS 12 01 2016.pdf Letter of Invitation MoH - Brazil	IC Document
1. GenIC Request Form - EEI Generic ICR.docx EEI GenIC Request - GBS Brazil	IC Document
FW URGENT 0920-1011 GenIC Request Guillian Barre Syndrome Brazil.msg Burden Statement - Email	IC Document

IC Title:

EEI Guillain-Barre Syndrome_Bahia Brazil

Agency IC Tracking Number:

0920-1011-16KM

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?	Electronic Capability
Form	NA	Case Control Questionnaire - GBS English	Appendix 1a. CaCo questionnaire.doc	NA	No	Paper Only
Form	NA	Case Control Questionnaire - GBS Portugese	Appendix 1b. CaCo questionnaire_Portuguese.doc	NA	No	Paper Only
Form	NA	Chart Abstraction Questionnaire - GBS English	Appendix 2a. Chart abstraction questionnaire.docx	NA	No	Paper Only
Form	NA	Chart Abstraction Questionnaire - GBS Portugese	Appendix 2b. Chart abstraction questionnaire_Portuguese.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 System Notice

FR Citation: 51 FR 42466

Number of Respondents: 90

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	140	140
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Invitation MoH - Brazil	LOI_CDC Atlanta_signed_Brazil GBS 12 01 2016.pdf	01/13/2016
EEI GenIC Request - GBS Brazil	1. GenIC Request Form - EEI Generic ICR.docx	01/13/2016
Burden Statement - Email	FW URGENT 0920-1011 GenIC Request Guillian Barre Syndrome Brazil.msg	01/13/2016

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