Information Collection

Resistant Gram-Negative Bacilli Case Report Form

IC 217336 under ICR 201705-0920-001 · OMB 0920-0978.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Resistant Gram-Negative Bacilli Case Report Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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?	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 %

table that charts list of burden
	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

table that charts IC Documents
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.