FluSurv-NET Influenza Hospitalization Surveilance Project Case Report Form

Emerging Infections Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:

Documents and Forms

Document Name Document Type
FluSurv-NET Influenza Hospitalization Surveilance Project Case Report Form Form
FluSurv-NET Influenza Hospital Surveillance Project Attachment 05_2014-15 FluSurv-NET Influenza Surveillance Project CRF.PDF Form
CDC Rev 07-2015 2015-16 FluSurv-NET Influenza Hospitalization Surveillan Att. 5 - FluSurv-NET Case Report Form.pdf Form

Information Collection (IC) Details

IC Title:	FluSurv-NET Influenza Hospitalization Surveilance Project Case Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	FluSurv-NET Influenza Hospital Surveillance Project	Attachment 05_2014-15 FluSurv-NET Influenza Surveillance Project CRF.PDF		Yes	Yes	Fillable Fileable
Form	CDC Rev 07-2015	2015-16 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form	Att. 5 - FluSurv-NET Case Report Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.