Information Collection

HAIC CDI Case Report Form

IC 217334 under ICR 201808-0920-022 · OMB 0920-0978.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0978 HAIC CDI Case Report Form	Form
0920-0978 Clostridium Difficile Infection (CDI) Surveillance Emerg CDI_2018CRF_25may2018.pdf	Form
0920-0978 CDI Case Report and Treatment Form Att 9 CDifficile-Form_17aug2018.pdf	Form and Instruction

IC Title:

HAIC CDI Case Report Form

Agency IC Tracking Number:

0920-0978-18AXU

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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
Form	0920-0978	Clostridium Difficile Infection (CDI) Surveillance Emerging Infections Program Case Report	CDI_2018CRF_25may2018.pdf	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0978	CDI Case Report and Treatment Form	Att 9 CDifficile-Form_17aug2018.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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	16,500	0	16,500
Annual IC Time Burden (Hours)	9,625	1,375	8,250
Annual IC Cost Burden (Dollars)	0	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.