Information Collection

2019-nCoV Investigation, United States, 2020

IC 239474 under ICR 202004-0920-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 2019 nCoV Case Report Form 2019-nCoV Investigation, United States, 2020	Form and Instruction
Form 0920-1011 2019 nCoV PUI Form 2019-nCoV Investigation, United States, 2020	Form and Instruction
Form 0920-1011 2019 nCoV Household Close Contact Investigation 2019-nCoV Investigation, United States, 2020	Form and Instruction
Form 0920-1011 Severe Pulmonary Disease Associatd with E-Cigarette Use Outbreak (Case Interview Short Form (CDC)) 2019-nCoV Investigation, United States, 2020	Form and Instruction
0920-1011 2019 nCoV Case Report Form Appendix 1 2019-nCoV Case Report Form (revised) (002).docx	Form and Instruction
0920-1011 2019 nCoV PUI Form Appendix 2 2019-nCoV PUI Form (revised).docx	Form and Instruction
0920-1011 2019 nCoV Household Close Contact Investigation Appendix 3 2019-nCoV nCoV Household-Close Contact Investigation Form (revised).docx	Form and Instruction
0920-1011 Severe Pulmonary Disease Associatd with E-Cigarette Use Appendix 2. Data Collection Forms.pdf	Form and Instruction
EpiAid_LetterOfSupport_NoCoVResponseOMBInitial_01222020.pdf EpiAid Letter of Support 2019 nCoV	IC Document
2020002-XXX nCoV_multi.docx GenIC Request EEI	IC Document
Burden Memo Email 2019 nCoV.msg Burden Memo Email	IC Document

IC Title:

2019-nCoV Investigation, United States, 2020

Agency IC Tracking Number:

0920-1011

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1011	2019 nCoV Case Report Form	Appendix 1 2019-nCoV Case Report Form (revised) (002).docx	NA	No		Paper Only
Form and Instruction	0920-1011	2019 nCoV PUI Form	Appendix 2 2019-nCoV PUI Form (revised).docx	NA	No		Paper Only
Form and Instruction	0920-1011	2019 nCoV Household Close Contact Investigation	Appendix 3 2019-nCoV nCoV Household-Close Contact Investigation Form (revised).docx	NA	No		Paper Only
Form and Instruction	0920-1011	Severe Pulmonary Disease Associatd with E-Cigarette Use Outbreak (Case Interview Short Form (CDC))	Appendix 2. Data Collection Forms.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemic Investigation Case Records - SORN number 09-20-0113

FR Citation: 51 FR 42466

Number of Respondents: 3,966

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
	Requested	Previously Approved
Annual Number of Responses for this IC	3,966	3,966
Annual IC Time Burden (Hours)	3,926	3,926
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
EpiAid Letter of Support 2019 nCoV	EpiAid_LetterOfSupport_NoCoVResponseOMBInitial_01222020.pdf	01/24/2020
GenIC Request EEI	2020002-XXX nCoV_multi.docx	01/24/2020
Burden Memo Email	Burden Memo Email 2019 nCoV.msg	01/24/2020

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