2019 Novel Coronavirus Airport Entry Questionnaires

Forms and Documents

Document Name	Status
Form 0920-20HF COVID-2019 Air Traveler Illness and Death Investigation Form Form and Instruction	New
Form 0920-20HF United States Travel Health Declaration for Repatriation from Ship Form and Instruction	New
Form 0920-20HF Supplemental 2019 Questionnaire Form and Instruction	New
Form 0920-20HF COVID-2019 Referral Slip Form and Instruction	New
Form 0920-20HF Preboarding Health Screen Form and Instruction	New
Form 0920-20HF United States Travel Health Declaration for Repatriation Form and Instruction	New
Form 0920-20HF United States Traveler Health Declaration Form and Instruction	New
Attachment L Wuhan Airport Entry Risk Assessment IRB.pdf Supplementary Document	2020-03-09
Attachment A2 42 CFR part 71.docx Supplementary Document	2020-03-09
Attachment A1 42 USC 264.pdf Supplementary Document	2020-03-09
SSB Emergency Clearance COVID-2019 Entry Risk Assessmentl-3.5.2020-Final-CLEAN.docx Supporting Statement B	2020-03-09
SSA Emergency Clearance COVID-2019 Entry Risk Assessment_3.5.2020_Final-CLEAN.docx Supporting Statement A	2020-03-09

IC Document Collections

IC ID	Document Title	Status
240643	COVID-2019 Air Traveler Illness and Death Investigation Form Form and Instruction	New
240642	United States Travel Health Declaration for Repatriation from Ship Form and Instruction	New
239872	Daily Sympton Check Other-Recorded	New
239871	Supplemental 2019 Questionnaire Form and Instruction	New
239870	COVID-2019 Referral Slip Form and Instruction	New
239869	Preboarding Health Screen Form and Instruction	New
239868	United States Travel Health Declaration for Repatriation Form and Instruction	New
239867	United States Traveler Health Declaration Form and Instruction	New

ICR Details

OMB Control No: 0920-1287	ICR Reference No: 202001-0920-020
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-20HF
Title: 2019 Novel Coronavirus Airport Entry Questionnaires
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 03/11/2020
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/12/2020
	Date Received in OIRA: 03/09/2020
Terms of Clearance: Approved consistent with the understanding that CDC will work with its desk officer to determine the appropriate pathway, should the agency request approval to revise or extend the collection beyond the approved period under this action. CDC will submit a request for any revisions to collection instruments, burden, or respondent population.The Agency will include the OMB control number, expiration date, and public burden statement on all instruments and instructions associated with this collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2020	6 Months From Approved
Responses	955,000	0	0
Time Burden (Hours)	136,667	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: CDC has been tasked with conducting public health assessments at U.S. airports of travelers coming from areas experiencing an outbreak of a novel (new) coronavirus (named “2019-nCoV”) in order to detect ill individuals or individuals at risk of being ill with 2019-nCoV. The goal of this information collection is to 1) accurately assess risk for infection or exposure to 2019-nCoV in travelers coming to the United States from locations experiencing an outbreak of 2019-nCoV, and 2) assist states in facilitating public health follow-up of contacts in the event of a confirmed case on an aircraft. The information will be used to determine if individuals meet risk thresholds for further medical evaluation or public health follow-up according to guidance developed by the CDC, and to assist health departments in facilitating public health follow-up, as appropriate.

Emergency Justfication: Pursuant to the Office of Management and Budget (OMB) procedures established at 5 CFR 1320, Controlling Paperwork Burdens on the Public, CDC requests that the following collection of information, 2019 Novel Coronavirus Airport Entry Questionnaires and Aircraft Contact Investigations Information Collection, be processed in accordance with section 1320.13 Emergency Processing. CDC has determined that this information must be collected prior to the expiration of time periods established under Part 1320, and that this information is essential to the CDC’s ability to effectively address the potential international public health crisis emanating from Wuhan City, Hubei Province, China, and which continues to expand. There is currently a lack of information concerning the risk of spread posed by the Novel (new) Coronavirus (“2019-nCoV”); however, thousands of cases have been identified in China, including outside of Hubei Province and infections are also being reported in a growing number of international locations, including the United States. This suggests there is a risk of international spread. To combat this, CDC, along with the Department of Homeland Security, will implement an enhanced risk assessment program at U.S airports for travelers from Wuhan, China. CDC may also require that travelers from additional countries be assessed for risk in the event that those locations represent a risk of spread to the United States.

---

Authorizing Statute(s): Statute at Large: 42 Stat. 71 Name of Statute: Foreign Quarantine
   US Code: 42 USC 264 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
United States Traveler Health Declaration	0920-20HF, 0920-20HF, 0920-20HF	US Traveler health Declaration Web ,   US Traveler Health Declaration Fillable PDF ,   US Traveler Health Declaration Paper
United States Travel Health Declaration for Repatriation	0920-20HF	US Traveler Health Declaration for Repatriation
Preboarding Health Screen	0920-20HF	Preboarding Health Screen
COVID-2019 Referral Slip	0920-20HF	Referral Slip
Supplemental 2019 Questionnaire	0920-20HF	Supplemental Questionnaire
Daily Sympton Check
United States Travel Health Declaration for Repatriation from Ship	0920-20HF	US Traveler Health Declaration Repatriation from Ship
COVID-2019 Air Traveler Illness and Death Investigation Form	0920-20HF	Air Traveler Illness or Death Investigation Form

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	955,000	0	0	955,000	0	0
Annual Time Burden (Hours)	136,667	0	0	136,667	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a New Emergency Collection.

---

Annual Cost to Federal Government: $17,500,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/09/2020

---