HAIC Multi-Site Gram-Negative Bacilli Case Report Form for Carbapenem-Resistant Pseudomonas ajeruginosa (CR-PA)

Emerging Infections Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0978 HAIC Multi-Site Gram-Negative Bacilli Case Report Form for Carbapenem-Resistant Pseudomonas ajeruginosa (CR-PA) Form
0920-0978 Carbapenem-resistant Pseudomonas aeruginosa Multi-Site G 21- MuGSI - CR-PA CRF_FINAL.PDF Form

Information Collection (IC) Details

IC Title:	HAIC Multi-Site Gram-Negative Bacilli Case Report Form for Carbapenem-Resistant Pseudomonas ajeruginosa (CR-PA)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	0920-0978	Carbapenem-resistant Pseudomonas aeruginosa Multi-Site Gram-Negative Surveillance (MuGSI) Case Report	21- MuGSI - CR-PA CRF_FINAL.PDF	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,440	3,440
Annual IC Time Burden (Hours)	2,580	2,580
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.