Information Collection

Acute Respiratory Infection and Influenza Surveillance Form

IC 212417 under ICR 201512-0920-009 · OMB 0920-1039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1039 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Acute Respiratory Infection and Influenza Surveillance Form	Form
Acute Respiratory Infection and Influenza Surveillance F Orchards ari surveillance form revised 12 22 15_1-temte.docx	Form

IC Title:

Acute Respiratory Infection and Influenza Surveillance Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Acute Respiratory Infection and Influenza Surveillance Form 28DEC2015	Orchards ari surveillance form revised 12 22 15_1-temte.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies, HHS/CDC.CHPE

FR Citation: 51 FR 42484

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	3,000	3,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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