Information Collection

Undetermined risk factors for long term sequela resulting from Rocky Mountain spotted fever-Arizona, 2018

IC 232337 under ICR 201810-0920-007 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1011 Undetermined risk factors for long term sequela resulting from Rocky Mountain spotted fever-Arizona, 2018	Form and Instruction
0920-1011 Patient Screening Questionnaire Appendix 2. Patient Screening Questionnaire_7-19-2018.pdf	Form and Instruction
0920-1011 Neurologial Examination Form Appendix 3. Neuro Exam Form.pdf	Form and Instruction
Letter of Invitation.pdf Letter of Invitation - AZ	IC Document
Burden Memo Email.msg Burden Memo Email	IC Document
IRB Approval.pdf IRB Approval	IC Document
2018001-XXX RMSF_AZ.docx GenIC Request - RMSF_AZ 2018	IC Document
Appendix 1. Chart Abstraction Form.pdf Chart Abstraction Form	IC Document

IC Title:

Undetermined risk factors for long term sequela resulting from Rocky Mountain spotted fever-Arizona, 2018

Agency IC Tracking Number:

0920-1011

IC Status: Unchanged

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 and Instruction	0920-1011	Patient Screening Questionnaire	Appendix 2. Patient Screening Questionnaire_7-19-2018.pdf	NA	No		Paper Only
Form and Instruction	0920-1011	Neurologial Examination Form	Appendix 3. Neuro Exam Form.pdf	NA	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0113 - Epidemic Investigation Case Records

FR Citation: 51 FR 42466

Number of Respondents: 375

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	375	375
Annual IC Time Burden (Hours)	126	126
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Invitation - AZ	Letter of Invitation.pdf	07/23/2018
Burden Memo Email	Burden Memo Email.msg	07/23/2018
IRB Approval	IRB Approval.pdf	07/23/2018
GenIC Request - RMSF_AZ 2018	2018001-XXX RMSF_AZ.docx	07/23/2018
Chart Abstraction Form	Appendix 1. Chart Abstraction Form.pdf	07/23/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.