Contact Investigation Outcome Reporting Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Influenza-like Illness Investigation Outcome Reporting Form - Maritime	Form	New	Available
Varicella Investigation Outcome Reporting Form	Form	New	Available
Script for DGMQ HotLine - Introduction	Form and Instruction	Removed	Available
Ebola Exposure Questionnaire for Passengers on Other Commercial Conveyances	Form and Instruction	Removed	Available
Ebola Exposure Questionnaire for Airport Staff	Form and Instruction	Removed	Repair queued
Ebola Exposure Questionnaire for Cleaning Crew	Form and Instruction	Removed	Available
Ebola Exposure Questionnaire for Flight Crew	Form and Instruction	Removed	Available
Ebola Exposure Questionnaire for Airline Passengers	Form and Instruction	Removed	Available
Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel)	Form	Removed	Available
State/Local Rubella Outcome Reporting (Air)	Form	Modified	Available
Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel)	Form	Removed	Available
Form 0920-0900 State/Local Measles Outcome Reporting (Air)	Form	Modified	Available
Cruise Ship TB Outcome Reporting - Maritime (Word)	Form	Modified	Available
State/Local TB Outcoming Reporting (Air)	Form	Modified	Available
State/Local General Outcome Reporting (Air)	Form	Modified	Available
Cruise Ship General Outcome Reporting -Maritime (Word & Excel)	Form	Removed	Available
State/Local General Contact Reporting (Land)	Form	Modified	Available
Attachment D 1_Summary of changes_Maritime TB Form.docx	Supplementary Document	Uploaded 2018-04-20	Available
0920-0900 2018 SupSta A 04202018.docx	Supporting Statement A	Uploaded 2018-04-20	Available
Attachment C - Non-research Determination.pdf	Supplementary Document	Uploaded 2018-04-20	Available
Attachment B 60 day Federal Register Notice.pdf	Supplementary Document	Uploaded 2018-04-20	Available
Attachment A3 42 CFR part 71.pdf	Supplementary Document	Uploaded 2018-04-20	Available
Attachment A2 42 CFR part 70.pdf	Supplementary Document	Uploaded 2018-04-20	Available
Attachment A1 Section 361 of the Public Health Service Act (42 USC 264).....pdf	Supplementary Document	Uploaded 2018-04-20	Available
0920-0900 2018 SupSta B 03282018.docx	Supporting Statement B	Uploaded 2018-04-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
231143	Influenza-like Illness Investigation Outcome Reporting Form - Maritime	Form	New
231142	Varicella Investigation Outcome Reporting Form	Form	New
215026	Script for DGMQ HotLine - Introduction	Form and Instruction	Removed
215025	Ebola Exposure Questionnaire for Passengers on Other Commercial Conveyances	Form and Instruction	Removed
215024	Ebola Exposure Questionnaire for Airport Staff	Form and Instruction	Removed
215020	Ebola Exposure Questionnaire for Cleaning Crew	Form and Instruction	Removed
215018	Ebola Exposure Questionnaire for Flight Crew	Form and Instruction	Removed
215017	Ebola Exposure Questionnaire for Airline Passengers	Form and Instruction	Removed
212223	Cruise Ship Rubella Outcome Reporting - Maritime (Word & Excel)	Form	Removed
212222	State/Local Rubella Outcome Reporting (Air)	Form	Modified
212221	Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel)	Form	Removed
197948	State/Local Measles Outcome Reporting (Air)	Form	Modified
197947	Cruise Ship TB Outcome Reporting - Maritime (Word)	Form	Modified
197946	State/Local TB Outcoming Reporting (Air)	Form	Modified
197945	State/Local General Outcome Reporting (Air)	Form	Modified
197944	Cruise Ship General Outcome Reporting -Maritime (Word & Excel)	Form	Removed
197943	State/Local General Contact Reporting (Land)	Form	Modified

ICR Details

OMB Control No: 0920-0900	ICR Reference No: 201802-0920-005
Status: Historical Active	Previous ICR Reference No: 201712-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0900-18GZ
Title: Contact Investigation Outcome Reporting Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/21/2018
	Date Received in OIRA: 04/20/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2021	36 Months From Approved	06/30/2018
Responses	1,036	0	6,495
Time Burden (Hours)	109	0	786
Cost Burden (Dollars)	4,055	0	0

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Abstract: The purpose of this information collection is to obtain sufficient information on the results of contact investigations carried out by state and local public health professionals or maritime medical crews to assess the impact of a confirmed communicable disease of public health concern in a traveler. Information is used to assess the impact in terms of spread and health outcomes and to determine if further public health intervention is appropriate. Communicable diseases of interest include clinically active tuberculosis (TB), varicella, influenza-like illness, measles, and rubella.

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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

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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:
	82 FR 47743	10/13/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 17418	04/19/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

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

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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	1,036	6,495	0	-5,459	0	0
Annual Time Burden (Hours)	109	786	0	-677	0	0
Annual Cost Burden (Dollars)	4,055	0	0	4,055	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This Revision incorporates new forms for 2 conditions: varicella and influenza-like illness. A number of forms were discontinued: non-TB maritime forms and all Ebola forms. The estimated number of TB contact investigation forms is lower, but the burden per response for each report is higher. Some forms include updated content. All changes are summarized in detail in Section A.15.

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Annual Cost to Federal Government: $221,716

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

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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: 04/20/2018

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