Information Collection

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

IC 230870 under ICR 201805-0920-010 · OMB 0920-0978.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	Approved	Previously Approved
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

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.