Contact investigation Outcome Reporting Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Script for DGMQ HotLine - Introduction, Flight and Seat Confirmation Ebola Air Contact Investigation	Form and Instruction	Unchanged	Available
Ebola Exposure Questionnaire for Passengers of Other Commercial Conveyances	Form and Instruction	Unchanged	Available
Ebola Exposure Questionnaire for Airport Staff	Form and Instruction	Unchanged	Available
Ebola Exposure Questionnaire for Cleaninig Crew	Form and Instruction	Unchanged	Available
Ebola Exposure Questionnaire for Flight Crew	Form and Instruction	Unchanged	Available
Ebola Exposure Questionnaire for Airline Passengers	Form and Instruction	Unchanged	Available
Rubella Maritime (Excel)	Form	Unchanged	Available
Rubella Maritime (Word)	Form	Unchanged	Repair queued
Form 0920-0900 Rubella Air Contact Investigation Outcome Reporting Form	Form	Modified	Available
Measles Maritime (Excel)	Form	Unchanged	Available
Measles Maritime (Word)	Form	Unchanged	Available
Form 0920-0900 Measles Air Contact Investigation Outcome Reporting Form	Form	Modified	Available
TB Maritime (Excel)	Form	Unchanged	Available
TB Maritime Word	Form	Unchanged	Available
Form 0920-0900 TB Air Contact Investigation Outcome Reportinig Form	Form	Modified	Available
General Contact Reporting (Land)	Form	Unchanged	Available
General Reporting Maritime (Word)	Form	Unchanged	Available
General Reporting Maritime (Excel)	Form	Unchanged	Available
Form 0920-0900 General Air Contact Investigation Outcome Reporting Form	Form	Modified	Available
0920-0900 Non Sub Change 11272017.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-12-14	Available
Rubella Contact Investigation Outcome Reporting Form_Track Changes.docx	Supplementary Document	Uploaded 2016-09-29	Available
Measles Contact Investigation Outcome Reporting From_Track Change.docx	Supplementary Document	Uploaded 2016-09-29	Available
TB Contact Investigation Outcome Reporting Form_Track Change.docx	Supplementary Document	Uploaded 2016-09-29	Available
General Contact Investigation Outcome Reporting Form_Track Change.docx	Supplementary Document	Uploaded 2016-09-29	Available
Non Substantive Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2016-09-27	Available
OMB package non-sub change to Contact Investigation.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-10-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
215026	Script for DGMQ HotLine - Introduction	Form and Instruction	Unchanged	Script for DGMQ HotLine - Introduction, Flight and Seat Confirmation Ebola Air Contact Investigation
215025	Ebola Exposure Questionnaire for Passengers on Other Commercial Conveyances	Form and Instruction	Unchanged	Ebola Exposure Questionnaire for Passengers of Other Commercial Conveyances
215024	Ebola Exposure Questionnaire for Airport Staff	Form and Instruction	Unchanged	Ebola Exposure Questionnaire for Airport Staff
215020	Ebola Exposure Questionnaire for Cleaning Crew	Form and Instruction	Unchanged	Ebola Exposure Questionnaire for Cleaninig Crew
215018	Ebola Exposure Questionnaire for Flight Crew	Form and Instruction	Unchanged	Ebola Exposure Questionnaire for Flight Crew
215017	Ebola Exposure Questionnaire for Airline Passengers	Form and Instruction	Unchanged	Ebola Exposure Questionnaire for Airline Passengers
212223	Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged	Rubella Maritime (Excel)
212223	Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged	Rubella Maritime (Word)
212222	State/Local Rubella Outcome Reporting (Air)	Form	Modified	Rubella Air Contact Investigation Outcome Reporting Form
212221	Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged	Measles Maritime (Excel)
212221	Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged	Measles Maritime (Word)
197948	State/Local Measles Outcome Reporting (Air)	Form	Modified	Measles Air Contact Investigation Outcome Reporting Form
197947	Cruise Ship TB Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged	TB Maritime (Excel)
197947	Cruise Ship TB Outcome Reporting - Maritime (Word & Excel)	Form	Unchanged	TB Maritime Word
197946	State/Local TB Outcoming Reporting (Air)	Form	Modified	TB Air Contact Investigation Outcome Reportinig Form
197945	State/Local General Outcome Reporting (Land)	Form	Unchanged	General Contact Reporting (Land)
197944	Cruise Ship General Outcome Reporting -Maritime (Word & Excel)	Form	Unchanged	General Reporting Maritime (Word)
197944	Cruise Ship General Outcome Reporting -Maritime (Word & Excel)	Form	Unchanged	General Reporting Maritime (Excel)
197943	State/Local General Contact Reporting (Air)	Form	Modified	General Air Contact Investigation Outcome Reporting Form

ICR Details

OMB Control No: 0920-0900	ICR Reference No: 201712-0920-005
Status: Historical Active	Previous ICR Reference No: 201609-0920-017
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0900-18GZ
Title: Contact investigation Outcome Reporting Forms
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/04/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/14/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2018	06/30/2018	06/30/2018
Responses	6,495	0	6,495
Time Burden (Hours)	786	0	786
Cost Burden (Dollars)	0	0	0

---

Abstract: CDC is requesting a Non-Substantive Change to 4 Forms (General, Measles, Rubella, TB) to allow the forms to be accessed regardless of individual HD network characteristics.

---

Authorizing Statute(s): US Code: 42 USC 264 Name of Law: The Public Health and Welfare
   US Code: 42 USC 70-71 Name of Law: Quarantine, Inspection, Licensing
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 74099	12/15/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 9725	02/24/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Cruise Ship General Outcome Reporting -Maritime (Word & Excel)	none, none	General Reporting Maritime (Excel) ,   General Reporting Maritime (Word)
Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel)	none, none	Measles Maritime (Word) ,   Measles Maritime (Excel)
Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel)	none, none	Rubella Maritime (Word) ,   Rubella Maritime (Excel)
Cruise Ship TB Outcome Reporting - Maritime (Word & Excel)	none, none	TB Maritime Word ,   TB Maritime (Excel)
Ebola Exposure Questionnaire for Airline Passengers	None	Ebola Exposure Questionnaire for Airline Passengers
Ebola Exposure Questionnaire for Airport Staff	None	Ebola Exposure Questionnaire for Airport Staff
Ebola Exposure Questionnaire for Cleaning Crew	None	Ebola Exposure Questionnaire for Cleaninig Crew
Ebola Exposure Questionnaire for Flight Crew	None	Ebola Exposure Questionnaire for Flight Crew
Ebola Exposure Questionnaire for Passengers on Other Commercial Conveyances	None	Ebola Exposure Questionnaire for Passengers of Other Commercial Conveyances
Script for DGMQ HotLine - Introduction	None	Script for DGMQ HotLine - Introduction, Flight and Seat Confirmation Ebola Air Contact Investigation
State/Local General Contact Reporting (Air)	0920-0900	General Air Contact Investigation Outcome Reporting Form
State/Local General Outcome Reporting (Land)	none	General Contact Reporting (Land)
State/Local Measles Outcome Reporting (Air)	0920-0900	Measles Air Contact Investigation Outcome Reporting Form
State/Local Rubella Outcome Reporting (Air)	0920-0900	Rubella Air Contact Investigation Outcome Reporting Form
State/Local TB Outcoming Reporting (Air)	0920-0900	TB Air Contact Investigation Outcome Reportinig Form

---

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	6,495	6,495	0	0	0	0
Annual Time Burden (Hours)	786	786	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $1,349,465

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

---

Common Form ICR:  No

---

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: 12/14/2017

---