Information Collection

HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB)

IC 217336 under ICR 202112-0920-010 · OMB 0920-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB)	Form and Instruction
2021 Carbapenem Resistant Enterobacteriaceae (CRE)/ Carb Att3_2021 MuGSI CRE CRAB CRF_102920.pdf	Form and Instruction
0920-0978 2022 Carbapenem Resistant Enterobacteriaceae (CRE)/ Carb Att3_MuGSI_CRE_CRAB_2022.pdf	Form

IC Title:

HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 PHSA

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	2021 Carbapenem Resistant Enterobacteriaceae (CRE)/ Carbapenem resistant A. baumannii (CRAB) MuGSI HAIC Case Report Form	Att3_2021 MuGSI CRE CRAB CRF_102920.pdf		Yes	Yes	Fillable Fileable
Form	0920-0978	2022 Carbapenem Resistant Enterobacteriaceae (CRE)/ Carbapenem resistant A. baumannii (CRAB) MuGSI HAIC Case Report Form	Att3_MuGSI_CRE_CRAB_2022.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	5,000	5,000
Annual IC Time Burden (Hours)	2,333	2,333
Annual IC Cost Burden (Dollars)	0	0

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.