Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Ebola Entry Screening Risk Assessment Form - Arabic	Form and Instruction	Removed	Available
Ebola Entry Screening Risk Assessment Form - French	Form and Instruction	Removed	Available
Ebola Entry Screening Risk Assessment Form - English	Form and Instruction	Removed	Available
Ebola Entry Screening Risk Assessment Form - Arabic	Form and Instruction	Removed	Available
Ebola Entry Screening Risk Assessment Form - French	Form and Instruction	Removed	Available
Ebola Entry Screening Risk Assessment Form - English	Form and Instruction	Removed	Available
United States Traveler Health Declaration - Arabic Translation Guide	Form and Instruction	Removed	Available
United States Traveler Health Declaration - French Translation Guide	Form and Instruction	Removed	Available
United States Health Declaration - English/PDF	Form and Instruction	Removed	Available
United States Traveler Health Declaration - English/Portal	Form and Instruction	Removed	Available
United States Traveler Health Declaration - English/Hard Copy	Form and Instruction	Removed	Available
Air Travel Illness or Death Investigation	Form	Modified	Available
Land Travel Illness or Death Investigation	Form	Modified	Available
Maritime Conveyance Illness or Death Investigation Form 0821_0134	Form and Instruction	Modified	Available
0920-0821 Revision Part B 02182016.docx	Supporting Statement B	Uploaded 2016-02-22	Available
0920-0821 Revision Part A 02182016.doc	Supporting Statement A	Uploaded 2016-02-22	Available
Attachment G Non-research Determination.pdf	Supplementary Document	Uploaded 2016-02-22	Available
Attachment B 60 Day FRN 0920-0821.pdf	Supplementary Document	Uploaded 2016-02-22	Available
Attachment A3 CFR-2013-title42-vol1-part71.pdf	Supplementary Document	Uploaded 2015-02-06	Available
Attachment A2 CFR-2013-title42-vol1-part70.pdf	Supplementary Document	Uploaded 2015-02-06	Available
Attachment A1 USCODE-2009-title42-chap6A-subchapII-partG.PDF	Supplementary Document	Uploaded 2015-02-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
214908	Ebola Entry Screening Risk Assessment (Ill Traveler Interview)	Form and Instruction	Removed	Ebola Entry Screening Risk Assessment Form - Arabic
214908	Ebola Entry Screening Risk Assessment (Ill Traveler Interview)	Form and Instruction	Removed	Ebola Entry Screening Risk Assessment Form - French
214908	Ebola Entry Screening Risk Assessment (Ill Traveler Interview)	Form and Instruction	Removed	Ebola Entry Screening Risk Assessment Form - English
214903	IVR Active Monitoring Survey - ARABIC (for translation service)	Other-IVR Telephone Survey Script (Limited number - English for	Removed
214902	IVR Active Monitoring Survey - FRENCH	Other-IVR Telephone Survey Script - French	Removed
214901	IVR Active Monitoring Survey - ENGLISH	Other-IVR Telephone Survey Script - English	Removed
214898	Ebola Entry Screening Risk Assessment - ARABIC	Form and Instruction	Removed	Ebola Entry Screening Risk Assessment Form - Arabic
214896	Ebola Entry Screening Risk Assessment - FRENCH	Form and Instruction	Removed	Ebola Entry Screening Risk Assessment Form - French
214895	Ebola Entry Screening Risk Assessment - ENGLISH	Form and Instruction	Removed	Ebola Entry Screening Risk Assessment Form - English
214893	United States Traveler Health Declaration - ARABIC	Form and Instruction	Removed	United States Traveler Health Declaration - Arabic Translation Guide
214890	United States Traveler Health Declaration - FRENCH	Form and Instruction	Removed	United States Traveler Health Declaration - French Translation Guide
214888	United States Traveler Health Declaration - ENGLISH	Form and Instruction	Removed	United States Health Declaration - English/PDF
214888	United States Traveler Health Declaration - ENGLISH	Form and Instruction	Removed	United States Traveler Health Declaration - English/Portal
214888	United States Traveler Health Declaration - ENGLISH	Form and Instruction	Removed	United States Traveler Health Declaration - English/Hard Copy
188000	Air Travel Illness or Death Investigation	Form	Modified	Air Travel Illness or Death Investigation
187999	Land Travel Illness or Death Investigation	Form	Modified	Land Travel Illness or Death Investigation
187997	International Maritime Conveyance Illness or Death Investigation Form	Form and Instruction	Modified	Maritime Conveyance Illness or Death Investigation Form 0821_0134

ICR Details

OMB Control No: 0920-0821	ICR Reference No: 201601-0920-011
Status: Historical Active	Previous ICR Reference No: 201502-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0821
Title: Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing
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: 06/03/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/01/2016
Terms of Clearance: This ICR is approved for 3 years as forms pertaining to Ebola screening have been removed from the collection and are no longer utilized.

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	2,650	0	1,129,429
Time Burden (Hours)	221	0	85,382
Cost Burden (Dollars)	0	0	0

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Abstract: Quarantine station staff work in partnership with international, federal, state, and local agencies and organizations to fulfill their mission to reduce morbidity and mortality among immigrants, refugees, travelers, expatriates, and other globally mobile persons. This request for Revision is to remove Respondents and Burden Hours associated with the United States Traveler Health Declaration, Ebola Entry Risk Assessment Forms, and the IVR Active Monitoring Survey System. No changes in data fields or collection processes are requested for the Air Travel, Maritime Conveyance, or Land Travel Illness or Death Investigation forms.

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Authorizing Statute(s): US Code: 42 USC 71 Name of Law: Foreign Quarantine
   US Code: 42 USC 264 Name of Law: Regulations to Control Communicable Diseases
   US Code: 42 USC 70 Name of Law: Interstate Quarrantine
  

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 78738	12/17/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 9198	02/24/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Air Travel Illness or Death Investigation	none	Air Travel Illness or Death Investigation
Ebola Entry Screening Risk Assessment (Ill Traveler Interview)	None, None, None	Ebola Entry Screening Risk Assessment Form - English ,   Ebola Entry Screening Risk Assessment Form - French ,   Ebola Entry Screening Risk Assessment Form - Arabic
Ebola Entry Screening Risk Assessment - ARABIC	None	Ebola Entry Screening Risk Assessment Form - Arabic
Ebola Entry Screening Risk Assessment - ENGLISH	None	Ebola Entry Screening Risk Assessment Form - English
Ebola Entry Screening Risk Assessment - FRENCH	None	Ebola Entry Screening Risk Assessment Form - French
IVR Active Monitoring Survey - ARABIC (for translation service)
IVR Active Monitoring Survey - ENGLISH
IVR Active Monitoring Survey - FRENCH
International Maritime Conveyance Illness or Death Investigation Form	NA	Maritime Conveyance Illness or Death Investigation Form 0821_0134
Land Travel Illness or Death Investigation	none	Land Travel Illness or Death Investigation
United States Traveler Health Declaration - ARABIC	None	United States Traveler Health Declaration - Arabic Translation Guide
United States Traveler Health Declaration - ENGLISH	None, None, None	United States Traveler Health Declaration - English/Hard Copy ,   United States Traveler Health Declaration - English/Portal ,   United States Health Declaration - English/PDF
United States Traveler Health Declaration - FRENCH	None	United States Traveler Health Declaration - French Translation Guide

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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	2,650	1,129,429	0	-1,126,779	0	0
Annual Time Burden (Hours)	221	85,382	0	-85,161	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: Revisions to 0920-0821 include an increase in the number of respondents/burden hours for the Air Travel Illness or Death Investigation form, and a decrease in respondents/burden hours for the Maritime Conveyance Illness or Death Investigation and Land Travel Illness or Death Investigation forms. Additionally, US Traveler Health Declaration and Ebola Risk Assessment Forms, IVR Script and Ebola Screening Risk Assessment forms and also being removed. This results in a net decrease in overall respondents/burden hours.

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Annual Cost to Federal Government: $467,353

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: 03/01/2016

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