Influenza Hospitalization Surveilance Network Case Report Form

Emerging Infections Program

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 0920-0978 Influenza Hospitalization Surveilance Network Case Report Form Form and Instruction
0920-0978 2017-18 FluSurv-NET Influenza Hospitalization Surveillan 11- 2017-18 FluSurv-NET Case Report Form.pdf Form
0920-0978 Influenza Hospitalization Surveillance Network Case Repo Att 4 -2018-19 FluSurv-NET CRF.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Influenza Hospitalization Surveilance Network Case Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0978	Influenza Hospitalization Surveillance Network Case Report Form	Att 4 -2018-19 FluSurv-NET CRF.pdf	NA	Yes	Yes	Fillable Fileable
Form	0920-0978	2017-18 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form	11- 2017-18 FluSurv-NET Case Report Form.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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10,000	10,000
Annual IC Time Burden (Hours)	4,167	4,167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.