Information Collection

Multistate outbreak of coccidioidomycosis (Valley fever) in U.S. students and adults who traveled to Tijuana area, Mexico

IC 234261 under ICR 201907-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Multistate outbreak of coccidioidomycosis (Valley fever) in U.S. students and adults who traveled to Tijuana area, Mexico	Form and Instruction
0920-1011 Patient Screening Questionnaire Appendix1_Questionnaire.doc	Form and Instruction
Investigation request - Valley fever - PRA application.pdf Investigation Request Memo	IC Document
0920-1011 GenIC Burden Memo Email.msg Burden Memo Email	IC Document
2019002-XXX Valley Fever_Multi.docx 0920-1011 GenIC Request	IC Document

IC Title:

Multistate outbreak of coccidioidomycosis (Valley fever) in U.S. students and adults who traveled to Tijuana area, Mexico

Agency IC Tracking Number:

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	Appendix1_Questionnaire.doc	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: 45

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	45	45
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Investigation Request Memo	Investigation request - Valley fever - PRA application.pdf	11/30/2018
Burden Memo Email	0920-1011 GenIC Burden Memo Email.msg	11/30/2018
0920-1011 GenIC Request	2019002-XXX Valley Fever_Multi.docx	11/30/2018

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