Information Collection

Initial Cluster Report

IC 236510 under ICR 202012-0920-004 · OMB 0920-0573.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0573 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Initial Cluster Report	Form and Instruction
Initial Cluster Report Form Att 3f_ Initial Cluster Report Form_rev18Jun19.pdf	Form and Instruction
Att 4f_Cluster Investigation Report Form Instructions 9.10.1.pdf Instructions: Cluster Investigation Reporting	IC Document

IC Title:

Initial Cluster Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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	n/a	Initial Cluster Report Form	Att 3f_ Initial Cluster Report Form_rev18Jun19.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC

FR Citation: 57 FR 62812

Number of Respondents: 59

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	148	148
Annual IC Time Burden (Hours)	148	148
Annual IC Cost Burden (Dollars)	3,996	3,996

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Instructions: Cluster Investigation Reporting	Att 4f_Cluster Investigation Report Form Instructions 9.10.1.pdf	06/26/2019

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