Emergency Epidemic Investigation Data Collections - Expedited Reviews

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Salmonella Infantis Infections among Detention Center Inmates - Case Interview Form	Form and Instruction	New	Available
HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CONTROL QUESTIONNAIRE	Form and Instruction	New	Available
HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CASE QUESTIONNAIRE	Form and Instruction	New	Available
Healthcare Professional Risk Assessment Questionnaire	Form and Instruction	New	Available
Community Member Questionnaire	Form and Instruction	New	Available
Focus Group Discussion Guide	Form and Instruction	New	Available
Questionnaire for Prison Outreak of Clostridium Botulinum, June 2016	Form and Instruction	New	Available
NYC Healthcare Worker Questionnaire	Form and Instruction	New	Available
CDC Call Script	Form and Instruction	New	Available
Contact Interview and Abstraction Form	Form and Instruction	New	Available
Case Interview Form	Form and Instruction	New	Available
Case Abstraction Form	Form and Instruction	New	Available
GBS_Columbia Chart Abstraction Form - Spanish	Form and Instruction	Unchanged	Available
GBS_Columbia Chart Abstraction Form - English	Form and Instruction	Unchanged	Available
GBS_Columbia Case Control Investigation Questionnaire - Spanish	Form and Instruction	Unchanged	Available
GBS_Columbia Case Control Investigation Questionnaire - English	Form and Instruction	Unchanged	Available
Festival A Interview Form	Form and Instruction	Unchanged	Available
Livestock Assessment Form	Form and Instruction	Unchanged	Available
Risk Factor Questionnaire	Form and Instruction	Unchanged	Available
Invasive GAS in Long Term Care Facility 2016 - Wound Care Survey	Form and Instruction	Unchanged	Available
Investigation of GAS outbreak in LTCF 2016 - Resident Record Extraction Form	Form and Instruction	Unchanged	Available
Invasive GAS in LTCF 2016 - Employee Survey	Form and Instruction	Unchanged	Available
Elizabethkingia Meningoseptica Case Investigation Form	Form and Instruction	Unchanged	Available
2016 Urgent Assessment of Blood Collection and Use in Puerto Rico in Response to the Zika Virus Outbreak	Form and Instruction	Unchanged	Available
Zika Virus Disease Case Investigation Form	Form and Instruction	Unchanged	Available
Chart Abstraction	Form	Unchanged	Available
Survey Questionnaire	Form and Instruction	Unchanged	Available
Zika Virus Disease Case Investigation Form	Form and Instruction	Unchanged	Available
Chart Abstraction Questionnaire - GBS Portugese	Form	Unchanged	Available
Chart Abstraction Questionnaire - GBS English	Form	Unchanged	Available
Case Control Questionnaire - GBS Portugese	Form	Unchanged	Available
Case Control Questionnaire - GBS English	Form	Unchanged	Available
Interview Form	Form	Unchanged	Available
Abstraction Form	Form	Unchanged	Available
Healthcare Worker Assessment	Form and Instruction	Unchanged	Available
Healthcare Worker Assessment	Form and Instruction	Unchanged	Available
Community Assessment - Spanish	Form and Instruction	Unchanged	Available
Community Assessment	Form and Instruction	Unchanged	Available
Sample Data Sheet	Form	Unchanged	Available
Legionella Environmental Assessment Form	Form and Instruction	Unchanged	Available
GAS_IL Employee Questionnaire	Form and Instruction	Unchanged	Available
GAS_IL Medical Record Abstraction	Form	Unchanged	Available
Public Health Official Interview Survey - French	Form and Instruction	Unchanged	Available
Public Health Official Interview Survey - English	Form and Instruction	Unchanged	Available
Rabies Official Interview Survey - French	Form and Instruction	Unchanged	Available
Rabies Official Interview Survey - English	Form and Instruction	Unchanged	Available
Medical Providers Interview Survey - French	Form and Instruction	Unchanged	Available
Medical Providers Interview Survey - English	Form and Instruction	Unchanged	Available
Community Survey - French	Form and Instruction	Unchanged	Available
Community Suyrvey - English	Form and Instruction	Unchanged	Available
HIV Risk Factors Interview Guide	Form and Instruction	Unchanged	Available
Records Abstraction Information	Form	Unchanged	Available
Interview Questions	Form	Unchanged	Available
Healthcare Worker Questionnaire	Form and Instruction	Unchanged	Available
Community Questionnaire	Form and Instruction	Unchanged	Available
Risk Assessment for Primate Research Center Employees and Inspectors	Form and Instruction	Unchanged	Available
Mucormycosis Data Abstraction Form	Form and Instruction	Unchanged	Available
Infection Prevention and Control Questions for Investigation of Mucormycosis	Form and Instruction	Unchanged	Available
Form CDC56.31A DENGUE Case Investigation Report	Form	Unchanged	Available
Consent	Form	Unchanged	Available
KAP Survey	Form	Unchanged	Available
Case Investigation	Form	Unchanged	Available
Appendix 2 - Ebola Case Contact Questionnaire	Form and Instruction	Unchanged	Available
Appendix 1 - Ebola Case Investigation Form	Form	Unchanged	Available
Focus Group Guide	Form and Instruction	Unchanged	Available
Field Guide	Form and Instruction	Unchanged	Available
Observation Guide	Form and Instruction	Unchanged	Available
Family Interview Questionnaire	Form	Unchanged	Available
Medical Chart Abstraction	Form	Unchanged	Available
Reprocessing Observation Checklist	Form	Unchanged	Available
Outpatient Dialysis Practices Survey	Form	Unchanged	Available
Chart Abstraction	Form	Unchanged	Available
Family interview	Form	Unchanged	Available
Chart Abstraction	Form	Unchanged	Available
Contact Listing Form	Form	Unchanged	Available
Case Report Form	Form	Unchanged	Available
Form 0920-1011 Appendix 2- Contact Tracing Form	Form	Unchanged	Available
Form 0920-1011 Appendix 1- Case Investigation Form	Form and Instruction	Unchanged	Available
Case Report (Spanish)	Form	Unchanged	Available
Case Report (English)	Form	Unchanged	Available
Individual Questionnaire	Form	Unchanged	Available
Household Questionnaire	Form	Unchanged	Available
Form CDC 56.31 A REV. 0 Dengue Case Investigation Report	Form and Instruction	Unchanged	Available
Case Questionnaire	Form	Unchanged	Available
Medical Abstraction Form	Form	Unchanged	Available
Interview Questionnaire	Form	Unchanged	Available
Record Abstraction	Form	Unchanged	Available
Follow-up Questionnaire for Asymptomatic Passengers and Crew	Form	Unchanged	Available
Questionnaire for Passengers and Crew	Form	Unchanged	Available
Appendix 2. Data Collection Forms.pdf	Supplementary Document	Uploaded 2016-04-27	Available
Appendix 1. Burden Memos.pdf	Supplementary Document	Uploaded 2016-04-27	Available
0920-1011 Non-Substantive Change Request Memo_Y2Q4_4-1-2016.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2016-04-27	Available
Appendix 2. Data Collection Forms.pdf	Supplementary Document	Uploaded 2016-01-27	Available
0920-1011 Non-Substantive Change Request Memo_Y2Q3_Subm 1-22-2016.docx	Supplementary Document	Uploaded 2016-01-27	Available
Appendix 1. Burden Memos.pdf	Supplementary Document	Uploaded 2016-01-27	Available
Appendix 2. Data Collection Forms_0920-1011.pdf	Supplementary Document	Uploaded 2015-11-03	Available
Appendix 1. Burden Memo_0920-1011.pdf	Supplementary Document	Uploaded 2015-11-03	Available
0920-1011 Non-Substantive Change Request Memo_Y2Q2_10-01-2015_Subm.docx	Supplementary Document	Uploaded 2015-11-03	Available
0920-1011 Non-Substantive Change Request Memo_Y2Q1_07-02-2015.docx	Supplementary Document	Uploaded 2015-07-07	Available
Appendix 2. Data Collection Forms.pdf	Supplementary Document	Uploaded 2015-07-07	Available
Appendix 1. Burden Memo.pdf	Supplementary Document	Uploaded 2015-07-07	Available
Appendix 1. Burden Memos.pdf	Supplementary Document	Uploaded 2015-04-22	Available
Appendix 2. Data Collection Forms.pdf	Supplementary Document	Uploaded 2015-04-22	Available
0920-1011 Non-Substantive Change Request Memo_Y1Q4_04-15-2015.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-04-22	Available
0920-1011 Non-Substantive Change Request Memo_Y1Q3_03-02-2015.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-03-03	Available
Appendix 1. Burden Memos.pdf	Supplementary Document	Uploaded 2015-03-03	Available
Appendix 2. Data Collection Forms.pdf	Supplementary Document	Uploaded 2015-03-03	Available
2014012-XXX_Burden Memo.docx	Supplementary Document	Uploaded 2014-10-29	Available
2014010-XXX_Burden Memo.docx	Supplementary Document	Uploaded 2014-10-29	Available
2014008-XXX Burden Memo.docx	Supplementary Document	Uploaded 2014-10-29	Available
2014007-XXX Burden Memo.docx	Supplementary Document	Uploaded 2014-10-29	Available
2014006-XXX Burden Memo.docx	Supplementary Document	Uploaded 2014-10-29	Available
2014005-XXX Burden Memo.docx	Supplementary Document	Uploaded 2014-10-29	Available
2014004-XXX Burden Memo.docx	Supplementary Document	Uploaded 2014-10-29	Available
2014003-XXX_Burden Memo.docx	Supplementary Document	Uploaded 2014-10-29	Available
Inventory.pdf	Supplementary Document	Uploaded 2014-10-29	Available
EEI GenICR 0920-1011_Attach E _Burden Memo_9_16_2014.docx	Supplementary Document	Uploaded 2014-10-29	Available
EEI GenICR 0920-0111_Attach D_Request for Approval 9-16-2014.docx	Supplementary Document	Uploaded 2014-10-29	Available
EEI GenICR 0920-1011_Attach C_ Steps Conduct Emer Epi Invest_10_20_14.docx	Supplementary Document	Uploaded 2014-10-29	Available
0920-1011 Non-Substantive Change Request Memo_revised.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-10-29	Available
EEI GenICR_Sup St B_3_20_14.docx	Supporting Statement B	Uploaded 2014-03-25	Available
EEI GenICR 0920-13ZJ_App 6_Online Survey Case Finding Questionnaire_11-06-2013.docx	Supplementary Document	Uploaded 2013-11-20	Available
EEI GenICR 0920-13ZJ_App 5_Phone Interview Questionnaire Patient_11-06-2013_Subm.docx	Supplementary Document	Uploaded 2013-11-20	Available
EEI GenICR 0920-13ZJ_App 4_Q Fever Person Interview Questionnaire_11-14-2013_Subm.docx	Supplementary Document	Uploaded 2013-11-20	Available
EEI GenICR 0920-13ZJ_App 3 _Hantav Pulm Synd Questionnaire_11-14-2013_Subm.docx	Supplementary Document	Uploaded 2013-11-20	Available
EEI GenICR 0920-13ZJ_App 2_GBS Case Questionnaire_11-14-2013_Subm.docx	Supplementary Document	Uploaded 2013-11-20	Available
EEI GenICR 0920-13ZJ_App 1_Chart Abstract Form_11-14-2013_Subm.docx	Supplementary Document	Uploaded 2013-11-20	Available
EEI GenICR 0920-13ZJ_Attach H_Biospecimen Storage Consent_11-06-2013_Subm.docx	Supplementary Document	Uploaded 2013-11-20	Available
EEI GenICR_0920-13ZJ_Attach G _Emer Epi Invest_IRB Letter_11-06-2013_Subm.pdf	Supplementary Document	Uploaded 2013-11-20	Available
EEI Gen ICR 0920-13ZJ_Attach F_Epi Invest SORN_11-06-2013.doc	Supplementary Document	Uploaded 2013-11-20	Available
EEI GenICR 0920-13ZJ_Attach E _Burden Memo_3-20-14.docx	Supplementary Document	Uploaded 2014-03-25	Available
EEI_Attach D_Request for Approval_3_20_14.docx	Supplementary Document	Uploaded 2014-03-25	Available
EEI GenICR 0920-13ZJ_Attach C_ Steps Conduct Emer Epi Invest_3_20_14.docx	Supplementary Document	Uploaded 2014-03-25	Available
EEI GenICR_0920-13ZJ_Attach B _Emer Epi Invest_Pub 60-day FRN_11-06-2013_Subm.pdf	Supplementary Document	Uploaded 2013-11-20	Available
EEI GenICR_0920-13ZJ_Attach A_Auth Legis Emer Epi Invest_11-06-2013_Subm.pdf	Supplementary Document	Uploaded 2013-11-20	Available
EEI_GenICR_Sup St A_3_20_14.docx	Supporting Statement A	Uploaded 2014-03-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
223019	Undetermined source for Salmonella Infantis infections among detention center inmates - South Carolina, 2016	Form and Instruction	New	Salmonella Infantis Infections among Detention Center Inmates - Case Interview Form
222856	Undetermined source, mode of transmission, and risk factors for Hepatitis A virus (HAV) transmission ‒ Hawaii, 2016	Form and Instruction	New	HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CONTROL QUESTIONNAIRE
222856	Undetermined source, mode of transmission, and risk factors for Hepatitis A virus (HAV) transmission ‒ Hawaii, 2016	Form and Instruction	New	HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CASE QUESTIONNAIRE
222590	Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016	Form and Instruction	New	Healthcare Professional Risk Assessment Questionnaire
222574	Undetermined Mode of Transmission_Zika Virus among Utah Community Members, 2016	Form and Instruction	New	Community Member Questionnaire
222478	Undetermined source of Elizabethkingia anophelis infections among Wisconsin residents - Wisconsin, 2016	Form and Instruction	New	Focus Group Discussion Guide
221903	Undetermined source and risk factors for botulism among prisoners at a correctional facility - Mississippi, 2016	Form and Instruction	New	Questionnaire for Prison Outreak of Clostridium Botulinum, June 2016
221731	Undetermined risk factors for Exophiala dermatitidis among oncology patients - New York City, 2016.	Form and Instruction	New	NYC Healthcare Worker Questionnaire
221731	Undetermined risk factors for Exophiala dermatitidis among oncology patients - New York City, 2016.	Form and Instruction	New	CDC Call Script
221388	Undetermined transmission and risk factors for multidrug-resistant Mycobacterium tuberculosis among Tribal members - Arizona, 2016	Form and Instruction	New	Contact Interview and Abstraction Form
221388	Undetermined transmission and risk factors for multidrug-resistant Mycobacterium tuberculosis among Tribal members - Arizona, 2016	Form and Instruction	New	Case Interview Form
221388	Undetermined transmission and risk factors for multidrug-resistant Mycobacterium tuberculosis among Tribal members - Arizona, 2016	Form and Instruction	New	Case Abstraction Form
220946	Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016	Form and Instruction	Unchanged	GBS_Columbia Chart Abstraction Form - Spanish
220946	Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016	Form and Instruction	Unchanged	GBS_Columbia Chart Abstraction Form - English
220946	Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016	Form and Instruction	Unchanged	GBS_Columbia Case Control Investigation Questionnaire - Spanish
220946	Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016	Form and Instruction	Unchanged	GBS_Columbia Case Control Investigation Questionnaire - English
220781	Undetermined risk factors for E.coli O157 among visitors to a goat dairy--Connecticut, 2016	Form and Instruction	Unchanged	Festival A Interview Form
220762	Undetermined sources and risk factors for a Rift Valley Fever Outbreak-Uganda, 2016	Form and Instruction	Unchanged	Livestock Assessment Form
220762	Undetermined sources and risk factors for a Rift Valley Fever Outbreak-Uganda, 2016	Form and Instruction	Unchanged	Risk Factor Questionnaire
220680	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	Unchanged	Invasive GAS in Long Term Care Facility 2016 - Wound Care Survey
220680	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	Unchanged	Investigation of GAS outbreak in LTCF 2016 - Resident Record Extraction Form
220680	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	Unchanged	Invasive GAS in LTCF 2016 - Employee Survey
220097	Undetermined source of Elizabethkingia meningoseptica bloodstream infection among Wisconsin residents - Wisconsin, 2016	Form and Instruction	Unchanged	Elizabethkingia Meningoseptica Case Investigation Form
220062	Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Puerto Rico, 2016	Form and Instruction	Unchanged	2016 Urgent Assessment of Blood Collection and Use in Puerto Rico in Response to the Zika Virus Outbreak
220062	Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Puerto Rico, 2016	Form and Instruction	Unchanged	Zika Virus Disease Case Investigation Form
220061	Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Brazil, 2016	Form	Unchanged	Chart Abstraction
220061	Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Brazil, 2016	Form and Instruction	Unchanged	Survey Questionnaire
220060	Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection – American Samoa, 2016	Form and Instruction	Unchanged	Zika Virus Disease Case Investigation Form
219577	EEI Guillain-Barre Syndrome_Bahia Brazil	Form	Unchanged	Chart Abstraction Questionnaire - GBS Portugese
219577	EEI Guillain-Barre Syndrome_Bahia Brazil	Form	Unchanged	Chart Abstraction Questionnaire - GBS English
219577	EEI Guillain-Barre Syndrome_Bahia Brazil	Form	Unchanged	Case Control Questionnaire - GBS Portugese
219577	EEI Guillain-Barre Syndrome_Bahia Brazil	Form	Unchanged	Case Control Questionnaire - GBS English
219234	Undetermined risk factors for ocular syphilis - North Carolina, 2015	Form	Unchanged	Interview Form
219234	Undetermined risk factors for ocular syphilis - North Carolina, 2015	Form	Unchanged	Abstraction Form
219193	Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015.	Form and Instruction	Unchanged	Healthcare Worker Assessment
219193	Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015.	Form and Instruction	Unchanged	Healthcare Worker Assessment
219193	Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015.	Form and Instruction	Unchanged	Community Assessment - Spanish
219193	Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015.	Form and Instruction	Unchanged	Community Assessment
218903	Undetermined Source of an outbreak of Legionnaires' Disease among Hotel A Visitors - Hannibal, MO 2015	Form	Unchanged	Sample Data Sheet
218903	Undetermined Source of an outbreak of Legionnaires' Disease among Hotel A Visitors - Hannibal, MO 2015	Form and Instruction	Unchanged	Legionella Environmental Assessment Form
218858	GAS_IL 2015	Form and Instruction	Unchanged	GAS_IL Employee Questionnaire
218858	GAS_IL 2015	Form	Unchanged	GAS_IL Medical Record Abstraction
218802	Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015	Form and Instruction	Unchanged	Public Health Official Interview Survey - French
218802	Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015	Form and Instruction	Unchanged	Public Health Official Interview Survey - English
218802	Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015	Form and Instruction	Unchanged	Rabies Official Interview Survey - French
218802	Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015	Form and Instruction	Unchanged	Rabies Official Interview Survey - English
218802	Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015	Form and Instruction	Unchanged	Medical Providers Interview Survey - French
218802	Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015	Form and Instruction	Unchanged	Medical Providers Interview Survey - English
218802	Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015	Form and Instruction	Unchanged	Community Survey - French
218802	Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015	Form and Instruction	Unchanged	Community Suyrvey - English
217928	Qualitative Investigation of HIV Transmission in Southeastern Indiana, 2015	Form and Instruction	Unchanged	HIV Risk Factors Interview Guide
217651	PA NTM	Form	Unchanged	Records Abstraction Information
217651	PA NTM	Form	Unchanged	Interview Questions
217021	Cholera_Kenya	Form and Instruction	Unchanged	Healthcare Worker Questionnaire
217021	Cholera_Kenya	Form and Instruction	Unchanged	Community Questionnaire
214996	Burkholderia Investigation_LA	Form and Instruction	Unchanged	Risk Assessment for Primate Research Center Employees and Inspectors
214724	Tainted Beverage_Mozambique	Other-WORD	Unchanged
214409	Mucormycosis_Kansas	Form and Instruction	Unchanged	Mucormycosis Data Abstraction Form
214409	Mucormycosis_Kansas	Form and Instruction	Unchanged	Infection Prevention and Control Questions for Investigation of Mucormycosis
214244	Dengue_AZ	Form	Unchanged	DENGUE Case Investigation Report
214244	Dengue_AZ	Other-WORD	Unchanged
213373	CCRF_Georgia	Form	Unchanged	Consent
213373	CCRF_Georgia	Form	Unchanged	KAP Survey
213373	CCRF_Georgia	Form	Unchanged	Case Investigation
213323	Ebola_TX	Form and Instruction	Unchanged	Appendix 2 - Ebola Case Contact Questionnaire
213323	Ebola_TX	Form	Unchanged	Appendix 1 - Ebola Case Investigation Form
213274	Ebola_West Africa_2014	Form and Instruction	Unchanged	Focus Group Guide
213274	Ebola_West Africa_2014	Form and Instruction	Unchanged	Field Guide
213274	Ebola_West Africa_2014	Form and Instruction	Unchanged	Observation Guide
213233	Pseudomonas NICU_CA	Other-WORD	Unchanged
213189	Pediatric cluster of neurologic symptoms - Colorado	Form	Unchanged	Family Interview Questionnaire
213189	Pediatric cluster of neurologic symptoms - Colorado	Form	Unchanged	Medical Chart Abstraction
213101	BSI_CA	Form	Unchanged	Reprocessing Observation Checklist
213101	BSI_CA	Form	Unchanged	Outpatient Dialysis Practices Survey
213101	BSI_CA	Form	Unchanged	Chart Abstraction
212908	2014016-XXX_Ebola_DRC	Other-WORD	Unchanged
212644	2014015-XXX_Parechovirus_Multi	Form	Unchanged	Family interview
212644	2014015-XXX_Parechovirus_Multi	Form	Unchanged	Chart Abstraction
212395	2014014-XXX Ebola_Sierra Leone	Other-PDF	Unchanged
212348	2014013-XXX_Resp Illness UAC_Multi	Other-WORD	Unchanged
212320	2014012-XXX Resp Illness UC_CA	Other-WORD	Unchanged
212266	2014011-XXX Ebola_Liberia	Form	Unchanged	Contact Listing Form
212266	2014011-XXX Ebola_Liberia	Form	Unchanged	Case Report Form
212227	2014009-XXX_Chikungunya_US Service Org Volunteers		Unchanged
212127	2014010-XXX Ebola_Guinea	Form	Unchanged	Appendix 2- Contact Tracing Form
212127	2014010-XXX Ebola_Guinea	Form and Instruction	Unchanged	Appendix 1- Case Investigation Form
211951	2014008-XXX Chikungunya_PR	Form	Unchanged	Case Report (Spanish)
211951	2014008-XXX Chikungunya_PR	Form	Unchanged	Case Report (English)
211951	2014008-XXX Chikungunya_PR	Form	Unchanged	Individual Questionnaire
211951	2014008-XXX Chikungunya_PR	Form	Unchanged	Household Questionnaire
211894	Chikungunya_USVI	Form and Instruction	Unchanged	Dengue Case Investigation Report
211894	Chikungunya_USVI	Other-WORD	Unchanged
211760	20140006XXX Measles FSM	Other-WORD	Unchanged
211705	2014005XXX_DiarrhealDisease_AS	Form	Unchanged	Case Questionnaire
211705	2014005XXX_DiarrhealDisease_AS	Form	Unchanged	Medical Abstraction Form
211702	2014004XXX_Legionnaires' Disease_Alabama 2014	Form	Unchanged	Interview Questionnaire
211702	2014004XXX_Legionnaires' Disease_Alabama 2014	Form	Unchanged	Record Abstraction
211682	2014E003XXX_MERS-CoV_GA	Form	Unchanged	Follow-up Questionnaire for Asymptomatic Passengers and Crew
211682	2014E003XXX_MERS-CoV_GA	Form	Unchanged	Questionnaire for Passengers and Crew

ICR Details

OMB Control No: 0920-1011	ICR Reference No: 201604-0920-011
Status: Historical Active	Previous ICR Reference No: 201601-0920-017
Agency/Subagency: HHS/CDC	Agency Tracking No: 16AGF
Title: Emergency Epidemic Investigation Data Collections - Expedited Reviews
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/02/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/28/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2017	03/31/2017	03/31/2017
Responses	36,000	0	36,000
Time Burden (Hours)	18,000	0	18,000
Cost Burden (Dollars)	0	0	0

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Abstract: CDC submits the quarterly inventory of forms and burden memos per agreement with OMB.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: PHSA
  

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:
	78 FR 41930	07/12/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 69854	11/21/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 49

table that charts list of burden

IC Title	Form No.	Form Name
20140006XXX Measles FSM
2014004XXX_Legionnaires' Disease_Alabama 2014	none, none	Record Abstraction ,   Interview Questionnaire
2014005XXX_DiarrhealDisease_AS	none, none	Medical Abstraction Form ,   Case Questionnaire
2014008-XXX Chikungunya_PR	none, none, none, none	Household Questionnaire ,   Individual Questionnaire ,   Case Report (English) ,   Case Report (Spanish)
2014009-XXX_Chikungunya_US Service Org Volunteers
2014010-XXX Ebola_Guinea	0920-1011, 0920-1011	Appendix 1- Case Investigation Form ,   Appendix 2- Contact Tracing Form
2014011-XXX Ebola_Liberia	none, none	Case Report Form ,   Contact Listing Form
2014012-XXX Resp Illness UC_CA
2014013-XXX_Resp Illness UAC_Multi
2014014-XXX Ebola_Sierra Leone
2014015-XXX_Parechovirus_Multi	none, none	Chart Abstraction ,   Family interview
2014016-XXX_Ebola_DRC
2014E003XXX_MERS-CoV_GA	none, none	Questionnaire for Passengers and Crew ,   Follow-up Questionnaire for Asymptomatic Passengers and Crew
BSI_CA	none, none, none	Chart Abstraction ,   Outpatient Dialysis Practices Survey ,   Reprocessing Observation Checklist
Burkholderia Investigation_LA	None	Risk Assessment for Primate Research Center Employees and Inspectors
CCRF_Georgia	none, none, none	Case Investigation ,   KAP Survey ,   Consent
Chikungunya_USVI	CDC 56.31 A REV. 06/2006	Dengue Case Investigation Report
Cholera_Kenya	None, None	Community Questionnaire ,   Healthcare Worker Questionnaire
Dengue_AZ	CDC56.31A	DENGUE Case Investigation Report
EEI Guillain-Barre Syndrome_Bahia Brazil	NA, NA, NA, NA	Case Control Questionnaire - GBS English ,   Case Control Questionnaire - GBS Portugese ,   Chart Abstraction Questionnaire - GBS English ,   Chart Abstraction Questionnaire - GBS Portugese
Ebola_TX	None, None	Appendix 1 - Ebola Case Investigation Form ,   Appendix 2 - Ebola Case Contact Questionnaire
Ebola_West Africa_2014	none, none, none	Observation Guide ,   Field Guide ,   Focus Group Guide
GAS_IL 2015	NA, NA	GAS_IL Medical Record Abstraction ,   GAS_IL Employee Questionnaire
Mucormycosis_Kansas	None, None	Infection Prevention and Control Questions for Investigation of Mucormycosis ,   Mucormycosis Data Abstraction Form
PA NTM	none, none	Interview Questions ,   Records Abstraction Information
Pediatric cluster of neurologic symptoms - Colorado	none, none	Medical Chart Abstraction ,   Family Interview Questionnaire
Pseudomonas NICU_CA
Qualitative Investigation of HIV Transmission in Southeastern Indiana, 2015	NA	HIV Risk Factors Interview Guide
Tainted Beverage_Mozambique
Undetermined Mode of Transmission_Zika Virus among Utah Community Members, 2016	NA	Community Member Questionnaire
Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016	NA	Healthcare Professional Risk Assessment Questionnaire
Undetermined Source of an outbreak of Legionnaires' Disease among Hotel A Visitors - Hannibal, MO 2015	NA, NA	Legionella Environmental Assessment Form ,   Sample Data Sheet
Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016	NA, NA, NA, NA	GBS_Columbia Case Control Investigation Questionnaire - English ,   GBS_Columbia Case Control Investigation Questionnaire - Spanish ,   GBS_Columbia Chart Abstraction Form - English ,   GBS_Columbia Chart Abstraction Form - Spanish
Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015	NA, NA, NA, NA, NA, NA, NA, NA	Community Suyrvey - English ,   Community Survey - French ,   Medical Providers Interview Survey - English ,   Medical Providers Interview Survey - French ,   Rabies Official Interview Survey - English ,   Rabies Official Interview Survey - French ,   Public Health Official Interview Survey - English ,   Public Health Official Interview Survey - French
Undetermined risk factors for E.coli O157 among visitors to a goat dairy--Connecticut, 2016	NA	Festival A Interview Form
Undetermined risk factors for Exophiala dermatitidis among oncology patients - New York City, 2016.	NA, NA	CDC Call Script ,   NYC Healthcare Worker Questionnaire
Undetermined risk factors for ocular syphilis - North Carolina, 2015	NA, NA	Abstraction Form ,   Interview Form
Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015.	NA, NA, NA, NA	Community Assessment ,   Community Assessment - Spanish ,   Healthcare Worker Assessment ,   Healthcare Worker Assessment
Undetermined source and risk factors for botulism among prisoners at a correctional facility - Mississippi, 2016	NA	Questionnaire for Prison Outreak of Clostridium Botulinum, June 2016
Undetermined source for Salmonella Infantis infections among detention center inmates - South Carolina, 2016	NA	Salmonella Infantis Infections among Detention Center Inmates - Case Interview Form
Undetermined source of Elizabethkingia anophelis infections among Wisconsin residents - Wisconsin, 2016	NA	Focus Group Discussion Guide
Undetermined source of Elizabethkingia meningoseptica bloodstream infection among Wisconsin residents - Wisconsin, 2016	NA	Elizabethkingia Meningoseptica Case Investigation Form
Undetermined source, mode of transmission, and risk factors for Hepatitis A virus (HAV) transmission ‒ Hawaii, 2016	NA, NA	HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CASE QUESTIONNAIRE ,   HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CONTROL QUESTIONNAIRE
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	NA, NA, NA	Invasive GAS in LTCF 2016 - Employee Survey ,   Investigation of GAS outbreak in LTCF 2016 - Resident Record Extraction Form ,   Invasive GAS in Long Term Care Facility 2016 - Wound Care Survey
Undetermined sources and risk factors for a Rift Valley Fever Outbreak-Uganda, 2016	NA, NA	Risk Factor Questionnaire ,   Livestock Assessment Form
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Brazil, 2016	NA, NA	Survey Questionnaire ,   Chart Abstraction
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Puerto Rico, 2016	NA, NA	Zika Virus Disease Case Investigation Form ,   2016 Urgent Assessment of Blood Collection and Use in Puerto Rico in Response to the Zika Virus Outbreak
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection – American Samoa, 2016	NA	Zika Virus Disease Case Investigation Form
Undetermined transmission and risk factors for multidrug-resistant Mycobacterium tuberculosis among Tribal members - Arizona, 2016	NA, NA, NA	Case Abstraction Form ,   Case Interview Form ,   Contact Interview and Abstraction Form

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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	36,000	36,000	0	0	0	0
Annual Time Burden (Hours)	18,000	18,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new generic information collection request.

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Annual Cost to Federal Government: $1,510,099

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: 04/28/2016

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