Information Collection

Evaluation of Emergency Use Fact Sheets Regarding Medical Countermeasures – Comprehension

IC 234826 under ICR 201806-0920-001 · OMB 0920-0572.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0572 Evaluation of Emergency Use Fact Sheets Regarding Medical Countermeasures – Comprehension	Form and Instruction
0920-0572 HMTS Evaluation Screener Attachment 1 - CDC Fact Sheet IDI Screener_11-19-18.doc	Form and Instruction
0920-0572 HMTS Evaluation Consent Form Attachment 2 - CDC Fact Sheet Consent Form_12-12-18.docx	Form and Instruction
0920-0572 HMTS Worksheet Activity Attachment 4 - CDC Fact Sheet Worksheet Activity_11-19-18.docx	Form and Instruction
0920-0572 HMTS Evaluation IDI Guide Attachment 3 - CDC Fact Sheet IDI Guide_12-11-18.docx	Form and Instruction
Attachment 5 - CDC Fact Sheet Screener Invitation Email_10-1-2018.docx Screener Invitatioin Email	IC Document
Attachment 6 - CDC Fact Sheet IDI Confirmation Email_12-11-18.docx IDI Confirmation Email	IC Document
Non-research determination_CDC NCEZID Human Subjects_121418_signed.pdf Non-Research Determination	IC Document
HMTS Expedited Review Form_OMB_Evaluation of Emergency Use Fact Sheets Regarding Medical Countermeasures 04FEB2019.pdf GenIC Request - HMTS Expedited Review	IC Document
Anthrax_Amoxicillin EUA Recipient FS_draft 05Oct18.pdf Fact Sheet - Anthrax_Amoxicillin	IC Document
Anthrax_AVA Dose-sparing EUA Recipient FS_draft 26Sept18.pdf Fact Sheet - Anthrax_AVA	IC Document
Anthrax_Doxycycline EUI Recipient FS_draft 05Oct18.pdf Fact Sheet - Anthrax_Doxycycline	IC Document
Botulism_BAT EUI Recipient FS_draft 04Oct18.pdf Fact Sheet - Botulism_BAT	IC Document
Burkholderia_Bactrim EUA Recipient FS_draft 20Sept17.pdf Fact Sheet - Burkholderia_Bactrim	IC Document
Burkholderia_Meropenem EUA Recipient FS_draft 28Mar18.pdf Fact Sheet - Burkholderia_Meropenem	IC Document
Influenza_IV Zanamivir EUA Recipient FS_draft 20Sept18.pdf Fact Sheet - Influenza_IV Zanamivir	IC Document
Influenza_Oseltamivir EUI Recipient FS_draft 24Oct18.pdf Fact Sheet - Influenza_Oseltamivir	IC Document
Influenza_Peramivir EUI Recipient FS_draft 24Oct18.pdf Fact Sheet - Influenza_Peramivir	IC Document
Plague_Ciprofloxacin_EUI Recipient FS_draft 27Feb18.pdf Fact Sheet - Plague_Ciprofloxacin	IC Document
Radiation_Neupogen EUI Recipient FS_draft 24Oct18.pdf Fact Sheet - Radiation_Neupogen	IC Document
Radiation_Radiogardase EUA Recipient FS_draft 23Oct18.pdf Fact Sheet - Radiation_Radiogardase	IC Document
Smallpox_ACAM2000 EUI Recipient FS_draft 24July18.pdf Fact Sheet - Smallpox_ACAM2000	IC Document
Smallpox_Tecovirimat EUI Recipient FS_draft 15Oct18.pdf Fat Sheet - Smallpox_Tecovirimat	IC Document
Tularemia_Gentamicin EUA Recipient FS_draft 01Oct18.pdf Fact Sheet - Tularemia_Gentamicin	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Evaluation of Emergency Use Fact Sheets Regarding Medical Countermeasures â Comprehension

Agency IC Tracking Number:

0920-0572-19PP

IC Status: New

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 and Instruction	0920-0572	HMTS Evaluation Screener	Attachment 1 - CDC Fact Sheet IDI Screener_11-19-18.doc	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	HMTS Evaluation Consent Form	Attachment 2 - CDC Fact Sheet Consent Form_12-12-18.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	HMTS Worksheet Activity	Attachment 4 - CDC Fact Sheet Worksheet Activity_11-19-18.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	HMTS Evaluation IDI Guide	Attachment 3 - CDC Fact Sheet IDI Guide_12-11-18.docx	NA	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 285

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	285	285
Annual IC Time Burden (Hours)	119	119
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screener Invitatioin Email	Attachment 5 - CDC Fact Sheet Screener Invitation Email_10-1-2018.docx	02/04/2019
IDI Confirmation Email	Attachment 6 - CDC Fact Sheet IDI Confirmation Email_12-11-18.docx	02/04/2019
Non-Research Determination	Non-research determination_CDC NCEZID Human Subjects_121418_signed.pdf	02/04/2019
GenIC Request - HMTS Expedited Review	HMTS Expedited Review Form_OMB_Evaluation of Emergency Use Fact Sheets Regarding Medical Countermeasures 04FEB2019.pdf	02/04/2019
Fact Sheet - Anthrax_Amoxicillin	Anthrax_Amoxicillin EUA Recipient FS_draft 05Oct18.pdf	02/04/2019
Fact Sheet - Anthrax_AVA	Anthrax_AVA Dose-sparing EUA Recipient FS_draft 26Sept18.pdf	02/04/2019
Fact Sheet - Anthrax_Doxycycline	Anthrax_Doxycycline EUI Recipient FS_draft 05Oct18.pdf	02/04/2019
Fact Sheet - Botulism_BAT	Botulism_BAT EUI Recipient FS_draft 04Oct18.pdf	02/04/2019
Fact Sheet - Burkholderia_Bactrim	Burkholderia_Bactrim EUA Recipient FS_draft 20Sept17.pdf	02/04/2019
Fact Sheet - Burkholderia_Meropenem	Burkholderia_Meropenem EUA Recipient FS_draft 28Mar18.pdf	02/04/2019
Fact Sheet - Influenza_IV Zanamivir	Influenza_IV Zanamivir EUA Recipient FS_draft 20Sept18.pdf	02/04/2019
Fact Sheet - Influenza_Oseltamivir	Influenza_Oseltamivir EUI Recipient FS_draft 24Oct18.pdf	02/04/2019
Fact Sheet - Influenza_Peramivir	Influenza_Peramivir EUI Recipient FS_draft 24Oct18.pdf	02/04/2019
Fact Sheet - Plague_Ciprofloxacin	Plague_Ciprofloxacin_EUI Recipient FS_draft 27Feb18.pdf	02/04/2019
Fact Sheet - Radiation_Neupogen	Radiation_Neupogen EUI Recipient FS_draft 24Oct18.pdf	02/04/2019
Fact Sheet - Radiation_Radiogardase	Radiation_Radiogardase EUA Recipient FS_draft 23Oct18.pdf	02/04/2019
Fact Sheet - Smallpox_ACAM2000	Smallpox_ACAM2000 EUI Recipient FS_draft 24July18.pdf	02/04/2019
Fat Sheet - Smallpox_Tecovirimat	Smallpox_Tecovirimat EUI Recipient FS_draft 15Oct18.pdf	02/04/2019
Fact Sheet - Tularemia_Gentamicin	Tularemia_Gentamicin EUA Recipient FS_draft 01Oct18.pdf	02/04/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.