HAIC CDI 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⚠️ Notice: This information collection may be referencing outdated material.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 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

Information Collection (IC) Details

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:

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 %

	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

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.