Information Collection

Demographic/Clinical Data Collection for Enhanced Surveillance

IC 232331 under ICR 201805-0920-005 · OMB 0920-0307.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0307 can be found here:

Documents and Forms

Document Name Document Type
Demographic/Clinical Data Collection for Enhanced Surveillance Form
Att 7_Data coding guide.docx Instruction
Demographic/Clinical Data Elements for Sites Conducting Att 3a2_enhanced clinic data_06212018.csv Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Demographic/Clinical Data Collection for Enhanced Surveillance	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	n/a	Demographic/Clinical Data Elements for Sites Conducting Enhanced Surveillance	Att 3a2_enhanced clinic data_06212018.csv		Yes	Yes	Fillable Fileable
Instruction			Att 7_Data coding guide.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136: Epidemiologic Studies and Surveillance of Disease Problems. HHS/CDCâ	FR Citation: 57 FR 62812

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	8,400	8,400
Annual IC Time Burden (Hours)	1,680	1,680
Annual IC Cost Burden (Dollars)	32,390	32,390

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.