National Disease Surveillance Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Acute Neurological Illness in Children Patient Summary Form	Form and Instruction	Removed	Available
Att H – PIA CJD, Reye Syndrome, Kawasaki syndrome.pdf	Supplementary Document	Uploaded 2016-06-02	Available
Att G – PIA AFM.pdf	Supplementary Document	Uploaded 2016-06-02	Available
Att C_Surveillance Summaries.docx	Supplementary Document	Uploaded 2016-01-04	Available
SSB 0009 10-5-15.docx	Supplementary Document	Uploaded 2016-01-04	Available
Att A_Authorizing_Regulations.doc	Supplementary Document	Uploaded 2016-01-04	Available
SSB 0009 10-5-15.docx	Supporting Statement B	Uploaded 2016-01-04	Available
SSA 0009_OMB rev 0416_NCIRD 0516.docx	Supporting Statement A	Uploaded 2016-06-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
219461	Att D-4_Acute Flaccid Myelitis	Other-WORD	New
219460	Att D-3_Reye Syndrome	Other-WORD	New
219459	Att D2_Kawasaki Syndrome	Other-WORD	New
219458	Att D-1_CJD	Other-WORD	New
213370	Acute Neurological Illness in Children Patient Summary Form	Form and Instruction	Removed

ICR Details

OMB Control No: 0920-0009	ICR Reference No: 201601-0920-001
Status: Historical Active	Previous ICR Reference No: 201502-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No: 0009
Title: National Disease Surveillance Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/02/2016
	Date Received in OIRA: 01/11/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2019	36 Months From Approved	06/30/2016
Responses	630	0	100
Time Burden (Hours)	190	0	50
Cost Burden (Dollars)	0	0	0

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Abstract: This is a revision of a surveillance package which includes CJD, Reye Syndrome, Kawasaki Syndrome and Acute Flaccid Myelitis disease surveillance. State Health Departments complete the forms and send the data to CDC without the identifiable information

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Research and Investigations Generally
   US Code: 42 USC 301 Name of Law: General Powers and Duties of Public Health Service
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 56997	09/21/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 78737	12/17/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Att D-4_Acute Flaccid Myelitis
Att D-3_Reye Syndrome
Acute Neurological Illness in Children Patient Summary Form	None	Acute Neurological Illness with Limb Weakness in Children: Patient Summary Form
Att D-1_CJD
Att D2_Kawasaki Syndrome

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	630	100	0	530	0	0
Annual Time Burden (Hours)	190	50	0	140	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There have been no changes to the disease surveillance.

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Annual Cost to Federal Government: $10,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/11/2016

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