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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1011 National Case Report Form - Standard E-cigarette associated Pulmonary Illness_Multi-State	Form and Instruction
Form 0920-1011 National Case Report Form - Abbreviated E-cigarette associated Pulmonary Illness_Multi-State	Form and Instruction
Form 0920-1011 Specimen Manifest Form E-cigarette associated Pulmonary Illness_Multi-State	Form
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

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:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Electronic Capability
Form and Instruction	0920-1011	NA	No	Paper Only
Form and Instruction	0920-1011	NA	No	Paper Only
Form	0920-1011	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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Invitation		11/26/2019
Medical Chart Abstraction Form (approved 8/29/2019)		11/26/2019
Case Interview Short Form (approved 8/29/2019)		11/26/2019
GenIC Request 0920-1011 EEI		11/26/2019
Burden Memo		11/26/2019

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

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