Att X Middle East Respiratory Syndrome Coronavirus (MERS) Patient Under Investigation (PUI) Form

National Disease Surveillance Program - II. Disease Summaries

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0004 can be found here:

Documents and Forms

Document Name Document Type
Att X Middle East Respiratory Syndrome Coronavirus (MERS) Patient Under Investigation (PUI) Form Form
Middle East Respiratory Syndrome (MERS) Patient Under In Attachment X_Middle East Respiratory Syndrome (MERS) Patient Under Investigation (PUI) Short Form.pdf Form

Information Collection (IC) Details

IC Title:	Att X Middle East Respiratory Syndrome Coronavirus (MERS) Patient Under Investigation (PUI) 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	None	Middle East Respiratory Syndrome (MERS) Patient Under Investigation (PUI) Short Form	Attachment X_Middle East Respiratory Syndrome (MERS) Patient Under Investigation (PUI) Short Form.pdf	NA	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 57	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	171	171
Annual IC Time Burden (Hours)	71	71
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.