Pediatric cluster of neurologic symptoms - Colorado

Emergency Epidemic Investigation Data Collections - Expedited Reviews

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Document Name Document Type
Pediatric cluster of neurologic symptoms - Colorado Form
Medical Chart Abstraction 2014018-XXX_Appendix 1.docx Form
Family Interview Questionnaire 2014018-XXX_Appendix 2.docx Form
2014018-XXX_Pediatric_CO.docx Application IC Document
CO letter of invitation.msg Letter of Invitation IC Document

Information Collection (IC) Details

IC Title:	Pediatric cluster of neurologic symptoms - Colorado	Agency IC Tracking Number:	14AZI

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Medical Chart Abstraction	2014018-XXX_Appendix 1.docx		Yes	Yes	Fillable Fileable
Form	none	Family Interview Questionnaire	2014018-XXX_Appendix 2.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Application	2014018-XXX_Pediatric_CO.docx	09/22/2014
Letter of Invitation	CO letter of invitation.msg	09/22/2014

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