Information Collection

Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016

IC 220680 under ICR 201601-0920-017 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016	Form and Instruction
Invasive GAS in LTCF 2016 - Employee Survey Appendix 1. Invasive GAS in LTCF 2016 Employee Survey.docx	Form and Instruction
Investigation of GAS outbreak in LTCF 2016 - Resident Re Appendix 2. Resident Record Extraction Form.docx	Form and Instruction
Invasive GAS in Long Term Care Facility 2016 - Wound Car Appendix 3. Wound Care Survey.docx	Form and Instruction
URGENT 0920-1011 GenIC Request GAS_Chicago_LTCF.msg Burden Memo Email	IC Document
IDPH Epi-Aid Request Letter 03172016.pdf Letter of Invitation - IDPH	IC Document
2016012-XXX_GAS_Chicago_LTCF.docx Emergency GenIC Request	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016

Agency IC Tracking Number:

16WB

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 and Instruction	NA	Invasive GAS in LTCF 2016 - Employee Survey	Appendix 1. Invasive GAS in LTCF 2016 Employee Survey.docx	NA	No	Paper Only
Form and Instruction	NA	Investigation of GAS outbreak in LTCF 2016 - Resident Record Extraction Form	Appendix 2. Resident Record Extraction Form.docx	NA	No	Paper Only
Form and Instruction	NA	Invasive GAS in Long Term Care Facility 2016 - Wound Care Survey	Appendix 3. Wound Care Survey.docx	NA	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemic Investigation Case Records - SORN number 09-20-0113

FR Citation: 51 FR 42466

Number of Respondents: 365

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	443	443
Annual IC Time Burden (Hours)	151	151
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Burden Memo Email	URGENT 0920-1011 GenIC Request GAS_Chicago_LTCF.msg	03/18/2016
Letter of Invitation - IDPH	IDPH Epi-Aid Request Letter 03172016.pdf	03/18/2016
Emergency GenIC Request	2016012-XXX_GAS_Chicago_LTCF.docx	03/18/2016

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