Information Collection

E-cigarette associated Pulmonary Illness_Multi-State

IC 238702 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 0920-1011 E-cigarette associated Pulmonary Illness_Multi-State Form and Instruction
0920-1011 National Case Report Form - Standard Appendix 1. National Case Report Form - Standard Version.docx Form and Instruction
0920-1011 National Case Report Form - Abbreviated Appendix 2. National Case Report Form - Abbreviated Version.docx Form and Instruction
0920-1011 Specimen Manifest Form Appendix 3. Specimen Manifest Form.docx Form
Letter of Invitation.pdf Letter of Invitation IC Document
Attachment A. Medical Chart Abstraction Short Form.docx Medical Chart Abstraction Form (approved 8/29/2019) IC Document
Attachment B. Case Interview Short Form.docx Case Interview Short Form (approved 8/29/2019) IC Document
2020001-XXX Pulmonary Illness_Multi.docx GenIC Request 0920-1011 EEI IC Document
Burden Memo Word.docx Burden Memo IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	E-cigarette associated Pulmonary Illness_Multi-State	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Electronic Capability
Form and Instruction	0920-1011	National Case Report Form - Standard	Appendix 1. National Case Report Form - Standard Version.docx	NA	No	Paper Only
Form and Instruction	0920-1011	National Case Report Form - Abbreviated	Appendix 2. National Case Report Form - Abbreviated Version.docx	NA	No	Paper Only
Form	0920-1011	Specimen Manifest Form	Appendix 3. Specimen Manifest Form.docx	NA	No	Paper Only

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records
Title: Epidemic Investigation Case Records - 09-20-0113	FR Citation: 51 FR 42466

Number of Respondents: 1,520	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,520	1,520
Annual IC Time Burden (Hours)	1,142	1,142
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Letter of Invitation	Letter of Invitation.pdf	11/26/2019
Medical Chart Abstraction Form (approved 8/29/2019)	Attachment A. Medical Chart Abstraction Short Form.docx	11/26/2019
Case Interview Short Form (approved 8/29/2019)	Attachment B. Case Interview Short Form.docx	11/26/2019
GenIC Request 0920-1011 EEI	2020001-XXX Pulmonary Illness_Multi.docx	11/26/2019
Burden Memo	Burden Memo Word.docx	11/26/2019

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