Information Collection

Case Report Evaluations

IC 205248 under ICR 201807-0920-006 · OMB 0920-0573.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0573 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Case Report Evaluations	Form and Instruction
Att_3c_NHSS_dataelements OMB 21Dec2015.pdf	Instruction
Adult HIV Confidential Case Report Form 2015 Att 3a_ACRF_PROOF242015.pdf	Form and Instruction
Pediatric HIV Confidential Case Report Form Att 3b_PCRF_PROOF112015.pdf	Form and Instruction

IC Title:

Case Report Evaluations

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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
Instruction			Att_3c_NHSS_dataelements OMB 21Dec2015.pdf	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Adult HIV Confidential Case Report Form 2015	Att 3a_ACRF_PROOF242015.pdf	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Pediatric HIV Confidential Case Report Form	Att 3b_PCRF_PROOF112015.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC

FR Citation: 57 FR 62812

Number of Respondents: 59

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	6,313	6,313
Annual IC Time Burden (Hours)	2,104	2,104
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.