Outbreak Summary Report Form

Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1353 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-21EE Outbreak Summary Report Form Form
0920-21EE Att 3e_Outbreak Summary Report Att 3e_Outbreak Summary Report_5-18-2021.docx Form
0920-21EE Att 3e_Outbreak Summary Report Att 3e_Outbreak Summary Report_5-18-2021_rev.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Outbreak Summary Report Form	Agency IC Tracking Number:	0920-21EE

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-21EE	Att 3e_Outbreak Summary Report	Att 3e_Outbreak Summary Report_5-18-2021_rev.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 59	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	118	118
Annual IC Time Burden (Hours)	39	39
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.