Contact Investigation Outcome Reporting Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
ILI Outbreak Enhanced Data Collection	Form and Instruction	Modified	Available
Varicella Investigation Outcome Reporting Form	Form	Unchanged	Available
Rubella Contact Investigation Outcome Reporting Form - Air	Form	Unchanged	Available
Measles Contact Investigation Outcome Reporting Form - Air	Form	Unchanged	Available
Form 0920-0900 Measles Air Contact Investigation Outcome Reporting Form	Form	Unchanged	Available
Clinically Active TB Contact Investigation Outcome Reporting Form - Maritime	Form	Unchanged	Available
TB Contact Investigation Outcome Reporting Form - Air	Form	Unchanged	Available
General Contact Investigation Outcome Reporting Form - Air	Form	Unchanged	Available
General Contact Investigation Outcome Reporting Form (Land)	Form	Unchanged	Available
0920-0900 ILI Non Sub Change 08282018.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2018-08-28	Available
Attachment D 1_Summary of changes_Maritime TB Form.docx	Supplementary Document	Uploaded 2018-04-20	Available
0920-0900 2018 SupSta A 04202018.docx	Supporting Statement A	Uploaded 2018-04-20	Available
Attachment C - Non-research Determination.pdf	Supplementary Document	Uploaded 2018-04-20	Available
Attachment B 60 day Federal Register Notice.pdf	Supplementary Document	Uploaded 2018-04-20	Available
Attachment A3 42 CFR part 71.pdf	Supplementary Document	Uploaded 2018-04-20	Available
Attachment A2 42 CFR part 70.pdf	Supplementary Document	Uploaded 2018-04-20	Available
Attachment A1 Section 361 of the Public Health Service Act (42 USC 264).....pdf	Supplementary Document	Uploaded 2018-04-20	Available
0920-0900 2018 SupSta B 03282018.docx	Supporting Statement B	Uploaded 2018-04-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
231143	Influenza-like Illness Investigation Outcome Reporting Form - Maritime	Form and Instruction	Modified	ILI Outbreak Enhanced Data Collection
231142	Varicella Investigation Outcome Reporting Form	Form	Unchanged	Varicella Investigation Outcome Reporting Form
212222	State/Local Rubella Outcome Reporting (Air)	Form	Unchanged	Rubella Contact Investigation Outcome Reporting Form - Air
197948	State/Local Measles Outcome Reporting (Air)	Form	Unchanged	Measles Contact Investigation Outcome Reporting Form - Air
197948	State/Local Measles Outcome Reporting (Air)	Form	Unchanged	Measles Air Contact Investigation Outcome Reporting Form
197947	Cruise Ship TB Outcome Reporting - Maritime (Word)	Form	Unchanged	Clinically Active TB Contact Investigation Outcome Reporting Form - Maritime
197946	State/Local TB Outcoming Reporting (Air)	Form	Unchanged	TB Contact Investigation Outcome Reporting Form - Air
197945	State/Local General Outcome Reporting (Air)	Form	Unchanged	General Contact Investigation Outcome Reporting Form - Air
197943	State/Local General Contact Reporting (Land)	Form	Unchanged	General Contact Investigation Outcome Reporting Form (Land)

ICR Details

OMB Control No: 0920-0900	ICR Reference No: 201808-0920-021
Status: Historical Active	Previous ICR Reference No: 201802-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-18AXV
Title: Contact Investigation Outcome Reporting Forms
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/29/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/29/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2021	05/31/2021	05/31/2021
Responses	1,036	0	1,036
Time Burden (Hours)	109	0	109
Cost Burden (Dollars)	4,055	0	4,055

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Abstract: The purpose of this information collection is to obtain sufficient information on the results of contact investigations carried out by state and local public health professionals or maritime medical crews to assess the impact of a confirmed communicable disease of public health concern in a traveler. Information is used to assess the impact in terms of spread and health outcomes and to determine if further public health intervention is appropriate. Communicable diseases of interest include clinically active tuberculosis (TB), varicella, influenza-like illness, measles, and rubella. The purpose of this non-substantive Change Request (submitted August 2018) is to clarify the wording of selected questions on the ILI Outbreak Enhanced Data Collection Form.

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Authorizing Statute(s): US Code: 42 USC 70-71 Name of Law: Quarantine, Inspection, Licensing
   US Code: 42 USC 264 Name of Law: The Public Health and Welfare
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 47743	10/13/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 17418	04/19/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Cruise Ship TB Outcome Reporting - Maritime (Word)	n/a	Clinically Active TB Contact Investigation Outcome Reporting Form - Maritime
Influenza-like Illness Investigation Outcome Reporting Form - Maritime	n/a	ILI Outbreak Enhanced Data Collection
State/Local General Contact Reporting (Land)	n/a	General Contact Investigation Outcome Reporting Form (Land)
State/Local General Outcome Reporting (Air)	n/a	General Contact Investigation Outcome Reporting Form - Air
State/Local Measles Outcome Reporting (Air)	0920-0900, n/a	Measles Air Contact Investigation Outcome Reporting Form ,   Measles Contact Investigation Outcome Reporting Form - Air
State/Local Rubella Outcome Reporting (Air)	n/a	Rubella Contact Investigation Outcome Reporting Form - Air
State/Local TB Outcoming Reporting (Air)	n/a	TB Contact Investigation Outcome Reporting Form - Air
Varicella Investigation Outcome Reporting Form	n/a	Varicella Investigation Outcome Reporting Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,036	1,036	0	0	0	0
Annual Time Burden (Hours)	109	109	0	0	0	0
Annual Cost Burden (Dollars)	4,055	4,055	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $221,716

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/29/2018

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