Information Collection

Demographic/Clinical Data for Sites Conducting Core Surveillance

IC 6747 under ICR 202106-0920-007 · OMB 0920-0307.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Demographic/Clinical Data for Sites Conducting Core Surveillance	Form
Att7 Data Coding Guide.docx	Instruction
Att7 Data Coding Guide.docx	Instruction
Core Demographic/Clinical Data Att3a1 Core surveillance clinical & demographic data.csv	Form
Core Demographic/Clinical Data Att3a1 Core surveillance clinical & demographic data.csv	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	n/a	Core Demographic/Clinical Data	Att3a1 Core surveillance clinical & demographic data.csv		Yes	Yes	Fillable Fileable
Instruction			Att7 Data Coding Guide.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136: Epidemiologic Studies and Surveillance of Disease Problems. HHS/CDCâ

FR Citation: 57 FR 62812

Number of Respondents: 20

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	4,800	4,800
Annual IC Time Burden (Hours)	880	880
Annual IC Cost Burden (Dollars)	16,966	16,966

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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