Information Collection for Tuberculosis Data from Referring Entities to Cure TB

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 16AWE Clinician Public Health Department Follow-Up Script - TB Treating Physicians	Form and Instruction	New	Available
Form 16AWE Cure TB Contact Source Investigation (CI/SI) Notification - Registered Nurses/Nurse Practitioners	Form and Instruction	New	Available
Form 16AWE Cure TB Transnational Notification - Tuberculosis (TB) Patients	Form and Instruction	New	Available
Form 16AWE Cure TB Transnational Notification - Registered Nurses/Nurse Practictioners	Form and Instruction	New	Available
Attachment C IRB Determination.pdf	Supplementary Document	Uploaded 2017-05-08	Available
Att A3 - 42 CFR 71.pdf	Supplementary Document	Uploaded 2017-05-08	Available
Att A2 - 42 CFR 70.pdf	Supplementary Document	Uploaded 2017-05-08	Available
Att A1 - Section 361 of the Public Health Service Act (42 USC 264).pdf	Supplementary Document	Uploaded 2017-05-08	Available
SupSta A CureTB final .docx	Supporting Statement A	Uploaded 2017-05-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
226739	Clinician Public Health Department Follow-Up Script - TB Treating Physicians	Form and Instruction	New
226738	Cure TB Contact Source Investigation (CI/SI) Notification - Registered Nurses/Nurse Practitioners	Form and Instruction	New
226737	Cure TB Transnational Notification - Tuberculosis (TB) Patients	Form and Instruction	New
226736	Cure TB Transnational Notification - Registered Nurses/Nurse Practictioners	Form and Instruction	New

ICR Details

OMB Control No: 0920-1186	ICR Reference No: 201705-0920-004
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 16AWE
Title: Information Collection for Tuberculosis Data from Referring Entities to Cure TB
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/02/2017
	Date Received in OIRA: 05/10/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved
Responses	2,200	0	0
Time Burden (Hours)	558	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The objective of this information collection is to facilitate CDC coordinating of the continuity of care for individuals affected by TB who enter US jurisdictions from foreign nations who or who leave US jurisdictions bound for foreign nations.

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Authorizing Statute(s): US Code: 42 USC Code of Federal Regulations Name of Law: Public Health Service Act
  

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:
	81 FR 52875	08/10/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 1339	01/05/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Clinician Public Health Department Follow-Up Script - TB Treating Physicians	16AWE	Attachment F CureTB Clinician_PHD Follow-up script
Cure TB Transnational Notification - Registered Nurses/Nurse Practictioners	16AWE	Attachment D CureTB_Transnational_Notification_CureTB 0722
Cure TB Transnational Notification - Tuberculosis (TB) Patients	16AWE	Attachment D CureTB_Transnational_Notification_CureTB 0722
Cure TB Contact Source Investigation (CI/SI) Notification - Registered Nurses/Nurse Practitioners	16AWE	Attachment E CureTB Contact_Source Investigation

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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	2,200	0	0	2,200	0	0
Annual Time Burden (Hours)	558	0	0	558	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new Information Collection Request, there are no changes

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Annual Cost to Federal Government: $112,108

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 05/10/2017

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