OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

[CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023

IC 256747 under ICR 202011-0920-003 · OMB 0920-0879.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 0920-0879
Pediatric Hepatitis - MEDICAL RECORD ABSTRACTION FORM [CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023		 Form
Form 0920-0879
Pediatric Hepatitis - Exposure Questionnaire [CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023		 Form
Form 0920-0879
Pediatric Hepatitis - Exposure Questionnaire (Spanish) [CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023		 Form
Form 0920-0879
Pediatric Hepatitis - Exposure Questionnaire CONTROL [CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023		 Form
Form 0920-0879
Pediatric Hepatitis - Exposure Questionnaire CONTROL (Spanish) [CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023		 Form
0920-0879 Pediatric Hepatitis - MEDICAL RECORD ABSTRACTION FORM
Attachment A_Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form Controls_MarOMBupdate.docx 		Form
0920-0879 Pediatric Hepatitis - Exposure Questionnaire
Attachment B_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire [Parental Interview]_MarOMBupdate.docx 		Form
0920-0879 Pediatric Hepatitis - Exposure Questionnaire (Spanish)
Attachment C_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire CONTROL [Parental Interview]_MarOMBupdate.docx 		Form
0920-0879 Pediatric Hepatitis - Exposure Questionnaire CONTROL
Attachment D_Hepatitis pediátrica de etiología desconocida - Cuestionario sobre exposiciones (entrevista a los padres). Spanish 		Form
0920-0879 Pediatric Hepatitis - Exposure Questionnaire CONTROL (Sp
Attachment E_Hepatitis pediátrica de etiología desconocida. CONTROL del cuestionario sobre exposiciones (Entrevista a los padres 		Form
Attachment F_Summary of Routine Calls.docx
Summary Routine Calls		IC Document
CSTLTS Generic Supporting_Statement_A_Guideline File_3Nov22_clean.docx
Supporting Statement A		IC Document
CSTLTS Generic Supporting_Statement_B_Guideline File_3Nov2022_clean.docx
Supporting Statement B		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 0920-0879 NA Yes Yes Fillable Fileable
Form 0920-0879 NA Yes Yes Fillable Fileable
Form 0920-0879 NA Yes Yes Fillable Fileable
Form 0920-0879 NA Yes Yes Fillable Fileable
Form 0920-0879 NA Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 520 0 520 0 0 0
Annual IC Time Burden (Hours) 390 0 390 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Summary Routine Calls 11/04/2022
Supporting Statement A 11/04/2022
Supporting Statement B 11/04/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].