Information Collection Request

Emerging Infections Program

ICR 201808-0920-022 · OMB 0920-0978 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 0920-0978 HAIC Candidemia Case Report Form Form and Instruction Modified Available
Form 0920-0978 HAIC Invasive Methicillin-Sensitive Staphylococcus aureus (MSSA) Form and Instruction Modified Available
Form 0920-0978 HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Form and Instruction Modified Available
Form 0920-0978 Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Form and Instruction Unchanged Available
Form 0920-0978 Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish) Form and Instruction Unchanged Available
Form 0920-0978 HAIC Multi-Site Gram-Negative Bacilli Case Report Form for Carbapenem-Resistant Pseudomonas ajeruginosa (CR-PA) Form Removed Available
Form 0920-0978 ABCs Severe GAS Infection Supplemental Form Form Unchanged Available
Form 17AHK ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form Form and Instruction Modified Available
HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB) Form Modified Available
Form 0920-0978 HAIC CDI Case Report Form Form Modified Available
ABCs Surveillance for Non-Invasive Pneumococcal Pneumonia (SNiPP) Case Report Form Form Removed Available
Form 0920-0978 FoodNet Yersinia Form Unchanged Available
Form 0920-0978 FoodNet Vibrio Form Unchanged Available
Form 0920-0978 FoodNet Shigella Form Unchanged Available
Form 0920-0978 FoodNet Shiga toxin producing E. coli Form Unchanged Available
Form 0920-0978 FoodNet Salmonella Form Unchanged Available
Form 0920-0978 FoodNet Listeria monocytogenes Form Unchanged Available
Form 0920-0978 FoodNet Cyclospora Form Unchanged Available
Form 0920-0978 FoodNet Cryptosporidium Form Unchanged Available
Form 0920-0978 FoodNet Campylobacter Form Unchanged Available
Form 0920-0978 Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English) Form and Instruction Unchanged Available
FoodNet Hemolytic Uremic Syndrome (HUS) Form Unchanged Available
Form 0920-0978 Influenza Hospitalization Surveilance Network Case Report Form Form and Instruction Modified Available
Form 17AHK ABCs Neonatal Infection Expanded Tracking Form Form and Instruction Modified Available
Form 17AHK ABCs Invasive Pneumococcal Disease in Children Form and Instruction Unchanged Available
Form 0920-0978 HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Form Modified Available
Form 17AHK ABCs Case Report Form Form and Instruction Modified Available
Non-sub change request_2018.doc Justification for No Material/Nonsubstantive Change Uploaded 2018-09-13 Available
CDI_Non-sub change request_FINAL_20180524.doc Justification for No Material/Nonsubstantive Change Uploaded 2018-05-31 Available
02- 60-Day FRN.PDF Supplementary Document Uploaded 2018-04-18 Available
Part B_EIP OMB Revision 20MAR2018.docx Supporting Statement B Uploaded 2018-03-29 Available
Part A_EIP OMB 2018 Revision_FINAL 28MAR2018.docx Supporting Statement A Uploaded 2018-03-29 Available
Non-sub change request_FINAL_20180118.doc Justification for No Material/Nonsubstantive Change Uploaded 2018-01-23 Available
Final EIP Justification OMB 0920-0978 nonsubstantive ABCs only April262017 CLEAN.doc Justification for No Material/Nonsubstantive Change Uploaded 2017-05-03 Available
EIP OMB 0920-0978 nonsub change request.doc Justification for No Material/Nonsubstantive Change Uploaded 2016-12-28 Available
Att. B - FoodNet Variable List_2016_SiteTransmitted.pdf Supplementary Document Uploaded 2016-12-28 Available
EIP 2016 Change Request.docx Justification for No Material/Nonsubstantive Change Uploaded 2016-03-02 Available
Attachment_25_ CDI ASSENT for 13-15.pdf Supplementary Document Uploaded 2015-07-07 Available
Attachment_24_ADULT VERBAL CONSENT Assent 16_17 for CDI.PDF Supplementary Document Uploaded 2015-07-07 Available
EIP 2015 Change Request_justification_revised 2-17-15.docx Justification for No Material/Nonsubstantive Change Uploaded 2015-02-17 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
231114 HAIC Candidemia Case Report Form Form and Instruction Modified
231113 HAIC Invasive Methicillin-Sensitive Staphylococcus aureus (MSSA) Form and Instruction Modified
231112 HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Form and Instruction Modified
231111 Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Form and Instruction Unchanged
231110 Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish) Form and Instruction Unchanged
230870 HAIC Multi-Site Gram-Negative Bacilli Case Report Form for Carbapenem-Resistant Pseudomonas ajeruginosa (CR-PA) Form Removed
230869 ABCs Severe GAS Infection Supplemental Form Form Unchanged
220380 ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form Form and Instruction Modified
217336 HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB) Form Modified
217334 HAIC CDI Case Report Form Form Modified
215016 ABCs Surveillance for Non-Invasive Pneumococcal Pneumonia (SNiPP) Case Report Form Form Removed
207663 FoodNet Yersinia Form Unchanged
207662 FoodNet Vibrio Form Unchanged
207661 FoodNet Shigella Form Unchanged
207660 FoodNet Shiga toxin producing E. coli Form Unchanged
207659 FoodNet Salmonella Form Unchanged
207658 FoodNet Listeria monocytogenes Form Unchanged
207657 FoodNet Cyclospora Form Unchanged
207656 FoodNet Cryptosporidium Form Unchanged
207655 FoodNet Campylobacter Form Unchanged
207653 Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English) Form and Instruction Unchanged
207652 FoodNet Hemolytic Uremic Syndrome (HUS) Form Unchanged
207651 Influenza Hospitalization Surveilance Network Case Report Form Form and Instruction Modified
207649 ABCs Neonatal Infection Expanded Tracking Form Form and Instruction Modified
207648 ABCs Invasive Pneumococcal Disease in Children Form and Instruction Unchanged
207647 HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Form Modified
207646 ABCs Case Report Form Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
05/31/2021 05/31/2021 05/31/2021
106,750 0 115,600
39,989 0 40,349
0 0 0





Reginfo record details
25
table that charts list of burden
IC Title Form No. Form Name
ABCs Neonatal Infection Expanded Tracking Form 17AHK, 0920-0978 Att. 3 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) Neonatal Infection Expanded Tracking Form ,   ABC Surveillance Neonatal Infection Expanded Tracking Form
Influenza Hospitalization Surveilance Network Case Report Form 0920-0978, 0920-0978 Influenza Hospitalization Surveillance Network Case Report Form ,   2017-18 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
FoodNet Hemolytic Uremic Syndrome (HUS) NA FoodNet Hemolytic Uremic Syndrome (HUS) Surveillance
Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English) 0920-0978, 0920-0978 FluServ-NET Consent Form - English ,   FluSurv-NET Vaccination Phone Script (English/Spanish)
FoodNet Campylobacter 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Cryptosporidium 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Cyclospora 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Listeria monocytogenes 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Salmonella 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Shigella 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Vibrio 0920-0978 FoodNet Variable List (site transmitted variables)
FoodNet Yersinia 0920-0978 FoodNet Variable List (site transmitted variables)
ABCs Invasive Pneumococcal Disease in Children 17AHK Att. 4 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) INVASIVE PNEUMOCOCCAL DISEASE IN CHILDREN
ABCs Surveillance for Non-Invasive Pneumococcal Pneumonia (SNiPP) Case Report Form none, CDC Non Bacteremic Pneumococcal 2015 ,   2016 Surveillance for Non-Invasive Penumococcal Pneumonia (SNiPP)
HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB) VERSION:01-2016, NA, 0920-09078, VERSION: 11/2017, 0920-0978 2015 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report ,   2016 Multi-site Gram Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report ,   2017 Multi-site Gram-Negative Surveillance Initiative (MuGSI) HAIC Case Report ,   2018 Multi-Site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report ,   MuGSI Case Report Form for Carbapenem-resistant Enterobacteriaceae (CRE) and Acinetobacter baumannii (CRAB)
ABCs Severe GAS Infection Supplemental Form 0920-0978 ABCs - Severe GAS Infection: Supplemental Form
HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) 0920-0978, 0920-0978 Surveillance for Extended-Spectrum Beta- Lactamase-Producing Enterobacteriaceae Multi-Site Gram-Negative Bacilli Surveillance (MuGSI) Healthcare Associated Infection Community Interface (HAIC) CRF ,   MuGSI Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae (ESBL)
HAIC Invasive Methicillin-Sensitive Staphylococcus aureus (MSSA) 0920-0978, 0920-0978 Invasive Methicillin-Sensitive Staphylococcus aureus Healthcare-Associated Infections Community Interface (HAIC) Case Report – 2018 ,   Invasive Methicillin-sensitive Staphylococcus aureus (MSSA) Infection Case Report Form
HAIC Candidemia Case Report Form 0920-0978, 0920-0978 HAIC Candidemia Case Report ,   CANDIDEMIA - CASE REPORT FORM
Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) 0920-0978 FluServ-NET Provider Vaccination History Fax Form
Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish) 0920-0978, 0920-0978 FluServ-NET Consent Form - Spanish ,   FluSurv-NET Vaccination Phone Script (English/Spanish)
HAIC Multi-Site Gram-Negative Bacilli Case Report Form for Carbapenem-Resistant Pseudomonas ajeruginosa (CR-PA) 0920-0978 Carbapenem-resistant Pseudomonas aeruginosa Multi-Site Gram-Negative Surveillance (MuGSI) Case Report
FoodNet Shiga toxin producing E. coli 0920-0978 FoodNet Variable List (site transmitted variables)
ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form 17AHK, 0920-0978 Att. 2 - ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form_HiNSES ,   ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form
HAIC CDI Case Report Form 0920-0978, 0920-0978 Clostridium Difficile Infection (CDI) Surveillance Emerging Infections Program Case Report ,   CDI Case Report and Treatment Form
ABCs Case Report Form 17AHK, 0920-0978 Att. 1 - 2017 ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT ,   2019 ABC Surveillance Case Report
HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) 0920-0978, 0920-0978 Invasive Methicillin-Resistant Staphylococcus aureaus Healthcare-Associated Infections Community Interface(HAIC) Case Report - 2018 ,   Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Infection Case Report Form

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 106,750 115,600 0 -4,160 -4,690 0
Annual Time Burden (Hours) 39,989 40,349 0 2,428 -2,788 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
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