Emerging Infections Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0978 CANDIDEMIA - CASE REPORT FORM	Form and Instruction	New	Available
Form 0920-0978 Invasive Methicillin-Sensitive Staphylococcus aureus Healthcare-Associated Infections Community Interface (HAIC) Case Report – 2018	Form and Instruction	New	Available
Form 0920-0978 Surveillance for Extended-Spectrum Beta- Lactamase-Producing Enterobacteriaceae Multi-Site Gram-Negative Bacilli Surveillance (MuGSI) Healthcare Associated Infection Community Interface (HAIC) CRF	Form and Instruction	New	Repair queued
Form 0920-0978 FluServ-NET Provider Vaccination History Fax Form	Form and Instruction	New	Repair queued
Form 0920-0978 FluSurv-NET Vaccination Phone Script (English/Spanish)	Form and Instruction	New	Available
Form 0920-0978 FluServ-NET Consent Form - Spanish	Form and Instruction	New	Repair queued
Form 0920-0978 Carbapenem-resistant Pseudomonas aeruginosa Multi-Site Gram-Negative Surveillance (MuGSI) Case Report	Form	New	Available
Form 0920-0978 ABCs - Severe GAS Infection: Supplemental Form	Form	New	Available
Form 17AHK Att. 2 - ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form_HiNSES	Form and Instruction	Modified	Available
Form 0920-09078 2018 Multi-Site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report	Form	Modified	Available
Form VERSION: 11/2017 2017 Multi-site Gram-Negative Surveillance Initiative (MuGSI) HAIC Case Report	Form	Modified	Available
Form VERSION:01-2016 2016 Multi-site Gram Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report	Form	Modified	Available
2015 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report	Form	Modified	Available
Form 0920-0978 Clostridium Difficile Infection (CDI) Surveillance Emerging Infections Program Case Report	Form	Modified	Available
Form CDC 2016 Surveillance for Non-Invasive Penumococcal Pneumonia (SNiPP)	Form	Modified	Available
Non Bacteremic Pneumococcal 2015	Form	Modified	Available
Form 0920-0978 FoodNet Variable List (site transmitted variables)	Form	Modified	Available
Form 0920-0978 FoodNet Variable List (site transmitted variables)	Form	Modified	Available
Form 0920-0978 FoodNet Variable List (site transmitted variables)	Form	Modified	Repair queued
Form 0920-0978 FoodNet Variable List (site transmitted variables)	Form	Modified	Available
Form 0920-0978 FoodNet Variable List (site transmitted variables)	Form	Modified	Available
Form 0920-0978 FoodNet Variable List (site transmitted variables)	Form	Modified	Available
Form 0920-0978 FoodNet Variable List (site transmitted variables)	Form	Modified	Repair queued
Form 0920-0978 FoodNet Variable List (site transmitted variables)	Form	Modified	Available
Form 0920-0978 FoodNet Variable List (site transmitted variables)	Form	Modified	Available
Consent	Form	Removed	Available
Form 0920-0978 FluSurv-NET Vaccination Phone Script (English/Spanish)	Form and Instruction	Modified	Repair queued
Form 0920-0978 FluServ-NET Consent Form - English	Form and Instruction	Modified	Available
FoodNet Hemolytic Uremic Syndrome (HUS) Surveillance	Form	Modified	Available
Form 0920-0978 2017-18 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form	Form	Modified	Repair queued
Form 17AHK Att. 3 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) Neonatal Infection Expanded Tracking Form	Form and Instruction	Unchanged	Available
Form 17AHK Att. 4 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) INVASIVE PNEUMOCOCCAL DISEASE IN CHILDREN	Form and Instruction	Unchanged	Available
Form 0920-0978 Invasive Methicillin-Resistant Staphylococcus aureaus Healthcare-Associated Infections Community Interface(HAIC) Case Report - 2018	Form	Modified	Available
Form 17AHK Att. 1 - 2017 ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT	Form and Instruction	Unchanged	Available
02- 60-Day FRN.PDF	Supplementary Document	Uploaded 2018-04-18	Available
Part B_EIP OMB Revision 20MAR2018.docx	Supporting Statement B	Uploaded 2018-03-29	Available
Part A_EIP OMB 2018 Revision_FINAL 28MAR2018.docx	Supporting Statement A	Uploaded 2018-03-29	Available
Non-sub change request_FINAL_20180118.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2018-01-23	Repair queued
Final EIP Justification OMB 0920-0978 nonsubstantive ABCs only April262017 CLEAN.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2017-05-03	Available
EIP OMB 0920-0978 nonsub change request.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2016-12-28	Available
Att. B - FoodNet Variable List_2016_SiteTransmitted.pdf	Supplementary Document	Uploaded 2016-12-28	Available
EIP 2016 Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2016-03-02	Available
Attachment_25_ CDI ASSENT for 13-15.pdf	Supplementary Document	Uploaded 2015-07-07	Available
Attachment_24_ADULT VERBAL CONSENT Assent 16_17 for CDI.PDF	Supplementary Document	Uploaded 2015-07-07	Available
EIP 2015 Change Request_justification_revised 2-17-15.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-02-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
231114	HAIC Candidemia Case Report Form	Form and Instruction	New	CANDIDEMIA - CASE REPORT FORM
231113	HAIC Invasive Methicillin-Sensitive Staphylococcus aureus (MSSA)	Form and Instruction	New	Invasive Methicillin-Sensitive Staphylococcus aureus Healthcare-Associated Infections Community Interface (HAIC) Case Report – 2018
231112	HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL)	Form and Instruction	New	Surveillance for Extended-Spectrum Beta- Lactamase-Producing Enterobacteriaceae Multi-Site Gram-Negative Bacilli Surveillance (MuGSI) Healthcare Associated Infection Community Interface (HAIC) CRF
231111	Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults)	Form and Instruction	New	FluServ-NET Provider Vaccination History Fax Form
231110	Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish)	Form and Instruction	New	FluSurv-NET Vaccination Phone Script (English/Spanish)
231110	Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish)	Form and Instruction	New	FluServ-NET Consent Form - Spanish
230870	HAIC Multi-Site Gram-Negative Bacilli Case Report Form for Carbapenem-Resistant Pseudomonas ajeruginosa (CR-PA)	Form	New	Carbapenem-resistant Pseudomonas aeruginosa Multi-Site Gram-Negative Surveillance (MuGSI) Case Report
230869	ABCs Severe GAS Infection Supplemental Form	Form	New	ABCs - Severe GAS Infection: Supplemental Form
220380	ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form	Form and Instruction	Modified	Att. 2 - ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form_HiNSES
217336	HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB)	Form	Modified	2018 Multi-Site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report
217336	HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB)	Form	Modified	2017 Multi-site Gram-Negative Surveillance Initiative (MuGSI) HAIC Case Report
217336	HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB)	Form	Modified	2016 Multi-site Gram Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report
217336	HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB)	Form	Modified	2015 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report
217334	HAIC CDI Case Report Form	Form	Modified	Clostridium Difficile Infection (CDI) Surveillance Emerging Infections Program Case Report
215016	ABCs Surveillance for Non-Invasive Pneumococcal Pneumonia (SNiPP) Case Report Form	Form	Modified	2016 Surveillance for Non-Invasive Penumococcal Pneumonia (SNiPP)
215016	ABCs Surveillance for Non-Invasive Pneumococcal Pneumonia (SNiPP) Case Report Form	Form	Modified	Non Bacteremic Pneumococcal 2015
207663	FoodNet Yersinia	Form	Modified	FoodNet Variable List (site transmitted variables)
207662	FoodNet Vibrio	Form	Modified	FoodNet Variable List (site transmitted variables)
207661	FoodNet Shigella	Form	Modified	FoodNet Variable List (site transmitted variables)
207660	FoodNet Shiga toxin producing E. coli	Form	Modified	FoodNet Variable List (site transmitted variables)
207659	FoodNet Salmonella	Form	Modified	FoodNet Variable List (site transmitted variables)
207658	FoodNet Listeria monocytogenes	Form	Modified	FoodNet Variable List (site transmitted variables)
207657	FoodNet Cyclospora	Form	Modified	FoodNet Variable List (site transmitted variables)
207656	FoodNet Cryptosporidium	Form	Modified	FoodNet Variable List (site transmitted variables)
207655	FoodNet Campylobacter	Form	Modified	FoodNet Variable List (site transmitted variables)
207654	FluSurv-Net Project Consent Form	Form	Removed	Consent
207653	Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English)	Form and Instruction	Modified	FluSurv-NET Vaccination Phone Script (English/Spanish)
207653	Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English)	Form and Instruction	Modified	FluServ-NET Consent Form - English
207652	FoodNet Hemolytic Uremic Syndrome (HUS)	Form	Modified	FoodNet Hemolytic Uremic Syndrome (HUS) Surveillance
207651	Influenza Hospitalization Surveilance Network Case Report Form	Form	Modified	2017-18 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
207649	ABCs Neonatal Infection Expanded Tracking Form	Form and Instruction	Unchanged	Att. 3 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) Neonatal Infection Expanded Tracking Form
207648	ABCs Invasive Pneumococcal Disease in Children	Form and Instruction	Unchanged	Att. 4 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) INVASIVE PNEUMOCOCCAL DISEASE IN CHILDREN
207647	HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA)	Form	Modified	Invasive Methicillin-Resistant Staphylococcus aureaus Healthcare-Associated Infections Community Interface(HAIC) Case Report - 2018
207646	ABCs Case Report Form	Form and Instruction	Unchanged	Att. 1 - 2017 ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT

ICR Details

OMB Control No: 0920-0978	ICR Reference No: 201803-0920-010
Status: Historical Active	Previous ICR Reference No: 201801-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0978
Title: Emerging Infections Program
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: 05/22/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/25/2018
Terms of Clearance: Previous terms continue: Approved consistent with the understanding that this consolidation will result in the modification and/or discontinuation of related CDC ICRs.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2021	36 Months From Approved	02/28/2019
Responses	115,600	0	62,820
Time Burden (Hours)	40,349	0	22,090
Cost Burden (Dollars)	0	0	0

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Abstract: The Emerging Infections Programs (EIP) is to 1) detect and monitor emerging pathogens, the diseases they cause, and the factors influencing their emergence, and respond to problems as they are identified, 2) integrate laboratory science and epidemiology to optimize public health practice, 3) strengthen infrastructure to support surveillance and research and to implement prevention and control programs, and to 4) ensure implementation of prevention strategies and communication of public health information about emerging diseases. Surveillance efforts of the core EIP activities generate reliable estimates of the incidence of certain infections and provide the foundation for a variety of epidemiologic studies. This Revision is being submitted to make existing forms clearer and to add several new forms: ABCs Severe GAS Infection Supplemental Form, HAIC Multi-site Gram-Negative Bacilli Case Report Form for Carbapenem-resistant Pseudomonas aeruginosa (CR-PA), HAIC Multi-site Gram-Negative Surveillance Initiative – Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae (MuGSI-ESBL), HAIC Invasive Methicillin-sensitive Staphylococcus aureus (MSSA), and HAIC Candidemia Case Report Form. These forms will allow the EIP to better detect, identify, and monitor emerging pathogens. The Revision results in an increase in 18,257 Burden Hours.

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Authorizing Statute(s): US Code: 42 USC 301 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:
	82 FR 60608	12/21/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 17412	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: 27

table that charts list of burden

IC Title	Form No.	Form Name
ABCs Case Report Form	17AHK	Att. 1 - 2017 ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT
ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form	17AHK	Att. 2 - ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form_HiNSES
ABCs Invasive Pneumococcal Disease in Children	17AHK	Att. 4 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) INVASIVE PNEUMOCOCCAL DISEASE IN CHILDREN
ABCs Neonatal Infection Expanded Tracking Form	17AHK	Att. 3 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) Neonatal Infection Expanded Tracking Form
ABCs Severe GAS Infection Supplemental Form	0920-0978	ABCs - Severe GAS Infection: Supplemental Form
ABCs Surveillance for Non-Invasive Pneumococcal Pneumonia (SNiPP) Case Report Form	none, CDC	Non Bacteremic Pneumococcal 2015 ,   2016 Surveillance for Non-Invasive Penumococcal Pneumonia (SNiPP)
FluSurv-Net Project Consent Form	none	Consent
FoodNet Campylobacter	0920-0978	FoodNet Variable List (site transmitted variables)
FoodNet Cryptosporidium	0920-0978	FoodNet Variable List (site transmitted variables)
FoodNet Cyclospora	0920-0978	FoodNet Variable List (site transmitted variables)
FoodNet Hemolytic Uremic Syndrome (HUS)	NA	FoodNet Hemolytic Uremic Syndrome (HUS) Surveillance
FoodNet Listeria monocytogenes	0920-0978	FoodNet Variable List (site transmitted variables)
FoodNet Salmonella	0920-0978	FoodNet Variable List (site transmitted variables)
FoodNet Shiga toxin producing E. coli	0920-0978	FoodNet Variable List (site transmitted variables)
FoodNet Shigella	0920-0978	FoodNet Variable List (site transmitted variables)
FoodNet Vibrio	0920-0978	FoodNet Variable List (site transmitted variables)
FoodNet Yersinia	0920-0978	FoodNet Variable List (site transmitted variables)
HAIC CDI Case Report Form	0920-0978	Clostridium Difficile Infection (CDI) Surveillance Emerging Infections Program Case Report
HAIC Candidemia Case Report Form	0920-0978	CANDIDEMIA - CASE REPORT FORM
HAIC Invasive Methicillin-Sensitive Staphylococcus aureus (MSSA)	0920-0978	Invasive Methicillin-Sensitive Staphylococcus aureus Healthcare-Associated Infections Community Interface (HAIC) Case Report – 2018
HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA)	0920-0978	Invasive Methicillin-Resistant Staphylococcus aureaus Healthcare-Associated Infections Community Interface(HAIC) Case Report - 2018
HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB)	VERSION:01-2016, NA, 0920-09078, VERSION: 11/2017	2015 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report ,   2016 Multi-site Gram Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report ,   2017 Multi-site Gram-Negative Surveillance Initiative (MuGSI) HAIC Case Report ,   2018 Multi-Site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report
HAIC Multi-Site Gram-Negative Bacilli Case Report Form for Carbapenem-Resistant Pseudomonas ajeruginosa (CR-PA)	0920-0978	Carbapenem-resistant Pseudomonas aeruginosa Multi-Site Gram-Negative Surveillance (MuGSI) Case Report
HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL)	0920-0978	Surveillance for Extended-Spectrum Beta- Lactamase-Producing Enterobacteriaceae Multi-Site Gram-Negative Bacilli Surveillance (MuGSI) Healthcare Associated Infection Community Interface (HAIC) CRF
Influenza Hospitalization Surveilance Network Case Report Form	0920-0978	2017-18 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults)	0920-0978	FluServ-NET Provider Vaccination History Fax Form
Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English)	0920-0978, 0920-0978	FluServ-NET Consent Form - English ,   FluSurv-NET Vaccination Phone Script (English/Spanish)
Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish)	0920-0978, 0920-0978	FluServ-NET Consent Form - Spanish ,   FluSurv-NET Vaccination Phone Script (English/Spanish)

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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	115,600	62,820	0	52,780	0	0
Annual Time Burden (Hours)	40,349	22,090	0	18,259	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Submission of 0920-0910 is a Revision that is being submitted to make existing forms clearer and to add several new forms. This results in an overall increase in 18,257 Burden Hours.

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Annual Cost to Federal Government: $31,091,990

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.     No

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: 04/25/2018

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