Information Collection

Consent for Linkage to Reportable Infectious Diseases Results

IC 216974 under ICR 202003-0920-021 · OMB 0920-0010.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0010 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Consent for Linkage to Reportable Infectious Diseases Results	Form and Instruction
Written Consent for Release of Reportable Infectious Dis AttL1_InfectionConsent.docx	Form and Instruction
Written Consent for Release of Reportable Infectious Dis AttL2_InfectionConsent_SPAN.docx	Form and Instruction
Verbal Consent for Release of Reportable Infectious Dise AttN1_InfectionVerbalConsent.docx	Form and Instruction
Verbal Consent for Release of Reportable Infectious Dise AttN2_InfectionVerbalConsent_SPAN.docx	Form and Instruction
AttM1_InfectionThankYouLtr.docx Thank You Letter for Infectious Diseases Reporting (English)	IC Document
AttM2_InfectionThankYouLtr_SPAN.docx Thank You Letter for Infectious Diseases Reporting (Spanish)	IC Document
AttY1_Infection_FAQ.docx FAQ about Reportable Infectious Diseases (English)	IC Document
AttY2_Infection_FAQ_SPAN.docx FAQ about Reportable Infectious Diseases (Spanish)	IC Document

IC Title:

Consent for Linkage to Reportable Infectious Diseases Results

Agency IC Tracking Number:

Is this a Common Form? No

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	Available Electronically?	Electronic Capability
Form and Instruction	n/a	Written Consent for Release of Reportable Infectious Diseases (English)	AttL1_InfectionConsent.docx	No	Paper Only
Form and Instruction	n/a	Written Consent for Release of Reportable Infectious Diseases (Spanish)	AttL2_InfectionConsent_SPAN.docx	No	Paper Only
Form and Instruction	n/a	Verbal Consent for Release of Reportable Infectious Diseases (English)	AttN1_InfectionVerbalConsent.docx	No	Paper Only
Form and Instruction	n/a	Verbal Consent for Release of Reportable Infectious Diseases (Spanish)	AttN2_InfectionVerbalConsent_SPAN.docx	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 2,590

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	Previously Approved
Annual Number of Responses for this IC	2,590	2,590
Annual IC Time Burden (Hours)	648	648
Annual IC Cost Burden (Dollars)	6,475	6,475

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Thank You Letter for Infectious Diseases Reporting (English)	AttM1_InfectionThankYouLtr.docx	08/26/2019
Thank You Letter for Infectious Diseases Reporting (Spanish)	AttM2_InfectionThankYouLtr_SPAN.docx	08/26/2019
FAQ about Reportable Infectious Diseases (English)	AttY1_Infection_FAQ.docx	08/26/2019
FAQ about Reportable Infectious Diseases (Spanish)	AttY2_Infection_FAQ_SPAN.docx	08/26/2019

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