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Influenza Hospitalization Surveilance Network Case Report Form

IC 207651 under ICR 201808-0920-022 · OMB 0920-0978.

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Document Name
Document Type
Form and Instruction
Form
Form and Instruction
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Influenza Hospitalization Surveilance Network Case Report Form
 
No Modified
 
Voluntary
 
42 CFR 301 Public Health Service Act

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

Health Consumer Health and Safety

 

10 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 10,000 0 0 0 0 10,000
Annual IC Time Burden (Hours) 4,167 0 0 0 0 4,167
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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