Information Collection

E-cigarette associated pulmonary illness

IC 237570 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⚠️ Notice: This information collection may be referencing outdated material.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 E-cigarette associated pulmonary illness	Form and Instruction
0920-1011 Case Interview Short Form - CDC 29AUG2019 Apendix 3. Case Interview Short Form_update3.docx	Form and Instruction
0920-1011 Medical Chart Abstraction Short Form - CDC 29AUG2019 Appendix 2. Medical Chart Abstraction Short Form_update3.docx	Form and Instruction
2019004-XXX Pulmonary Illness_Multi.docx EEI - GenIC Request	IC Document
Letter of Invitation.pdf Letter of Invitation	IC Document
Appendix 1. Case Definition.docx Case Definition	IC Document
Burden Memo.msg Burden Memo	IC Document

IC Title:

E-cigarette associated pulmonary illness

Agency IC Tracking Number:

0920-1011-19BPM

IC Status: New

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	Case Interview Short Form - CDC 29AUG2019	Apendix 3. Case Interview Short Form_update3.docx	NA	No		Paper Only
Form and Instruction	0920-1011	Medical Chart Abstraction Short Form - CDC 29AUG2019	Appendix 2. Medical Chart Abstraction Short Form_update3.docx	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: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
EEI - GenIC Request	2019004-XXX Pulmonary Illness_Multi.docx	08/28/2019
Letter of Invitation	Letter of Invitation.pdf	08/28/2019
Case Definition	Appendix 1. Case Definition.docx	08/28/2019
Burden Memo	Burden Memo.msg	08/28/2019

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