Resistant Gram-Negative Bacilli 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⚠️ Notice: This information collection may be referencing outdated material.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
Resistant Gram-Negative Bacilli Case Report Form Form
2015 Multi-site Gram-Negative Surveillance Initiative (M Attachment_28_MDR GNB CRF_0920-0978.pdf Form
VERSION:01-2016 2016 Multi-site Gram Negative Surveillance Initiative (M Att. 8 - MUGSI Form.pdf Form
VERSION: 11/2017 2017 Multi-site Gram-Negative Surveillance Initiative (M Att. D -16_271030_HAIC-MuGSI_2017_OMB_v3.pdf Form

Information Collection (IC) Details

IC Title:	Resistant Gram-Negative Bacilli Case Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NA	2015 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report	Attachment_28_MDR GNB CRF_0920-0978.pdf	NA	Yes	Yes	Fillable Fileable
Form	VERSION:01-2016	2016 Multi-site Gram Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report	Att. 8 - MUGSI Form.pdf		Yes	Yes	Fillable Fileable
Form	VERSION: 11/2017	2017 Multi-site Gram-Negative Surveillance Initiative (MuGSI) HAIC Case Report	Att. D -16_271030_HAIC-MuGSI_2017_OMB_v3.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

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	5,000	5,000
Annual IC Time Burden (Hours)	1,667	1,667
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.