2014008-XXX Chikungunya_PR

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⚠️ Notice: This information collection may be referencing outdated material.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
2014008-XXX Chikungunya_PR Form
Household Questionnaire Appendix 1 - Household questionnaire.pdf Form
Individual Questionnaire Appendix 2 - Individual quesionnaire.pdf Form
Case Report (English) Appendix 3a - Case Reporting Form [English].pdf Form
Case Report (Spanish) Appendix 3b - Spanish Case reporting form.pdf Form
Request for Approval Chikungunya_PR.docx Request for Approval IC Document
Letter of Invitation Chikungunya_PR.pdf Letter of Invitation IC Document

Information Collection (IC) Details

IC Title:	2014008-XXX Chikungunya_PR	Agency IC Tracking Number:	0920-14AJK

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR Public Health Service Act (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	none	Household Questionnaire	Appendix 1 - Household questionnaire.pdf	No	Paper Only
Form	none	Individual Questionnaire	Appendix 2 - Individual quesionnaire.pdf	No	Paper Only
Form	none	Case Report (English)	Appendix 3a - Case Reporting Form [English].pdf	No	Paper Only
Form	none	Case Report (Spanish)	Appendix 3b - Spanish Case reporting form.pdf	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0113 Epidemic Investigation Case Records HHS/CDC	FR Citation: 51 FR 42466

Number of Respondents: 6,256	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	6,256	6,256
Annual IC Time Burden (Hours)	1,564	1,564
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	Request for Approval Chikungunya_PR.docx	06/18/2014
Letter of Invitation	Letter of Invitation Chikungunya_PR.pdf	06/18/2014

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