Information Collection

Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022

IC 252724 under ICR 202201-0920-010 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1011 Aggregate counts of persons exposed to HPAI Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022	Form and Instruction
Form 0920-1011 HPAI H5 Consent Form (English) Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022	Form and Instruction
Form 0920-1011 HPAI H5 Consent Form (Spanish) Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022	Form and Instruction
Form 0920-1011 Avian Influenza Initial Case Investigation Form (English) Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022	Form and Instruction
Form 0920-1011 Avian Influenza Initial Case Investigation Form (Spanish) Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022	Form and Instruction
Form 0920-1011 Highly Pathogenic Avian Influenza A (H5N1) Exposure Questionnaire (English) Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022	Form and Instruction
Form 0920-1011 Highly Pathogenic Avian Influenza A (H5N1) Exposure Questionnaire (Spanish) Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022	Form and Instruction
Form 0920-1011 HPAI H5 Self Swab Instructions (English) Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022	Form and Instruction
Form 0920-1011 HPAI H5 Self Swab Instructions (Spanish) Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022	Form and Instruction
Form 0920-1011 Human Sera Collection Guidelines for Flu Serology Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022	Form and Instruction
0920-1011 Aggregate counts of persons exposed to HPAI Appendix 1. Aggregate counts of persons exposed to highly pathogenic avian influenza (HPAI).docx	Form and Instruction
0920-1011 HPAI H5 Consent Form (English) Appendix 2. HPAIH5_ConsentForm_20220311_FINAL.docx	Form and Instruction
0920-1011 HPAI H5 Consent Form (Spanish) Appendix 3. HPAIH5_ConsentForm_20220311_FINAL_SPANISH.docx	Form and Instruction
0920-1011 Avian Influenza Initial Case Investigation Form (English Appendix 4. HPAIH5_InitialCaseInvestigationForm_20220321_FINAL.docx	Form and Instruction
0920-1011 Avian Influenza Initial Case Investigation Form (Spanish Appendix 5. HPAIH5_InitialCaseInvestigationForm_20220321_FINAL_SPANISH.docx	Form and Instruction
0920-1011 Highly Pathogenic Avian Influenza A (H5N1) Exposure Ques Appendix 6. HPAIH5_Questionnaire_20220324_FINAL.docx	Form and Instruction
0920-1011 Highly Pathogenic Avian Influenza A (H5N1) Exposure Ques Appendix 7. HPAIH5_Questionnaire_20220324_FINAL_SPANISH.docx	Form and Instruction
0920-1011 HPAI H5 Self Swab Instructions (English) Appendix 8. HPAIH5_selfswabinstructions.pptx	Form and Instruction
0920-1011 HPAI H5 Self Swab Instructions (Spanish) Appendix 9. HPAIH5_selfswabinstructions_SPANISH.pptx	Form and Instruction
0920-1011 Human Sera Collection Guidelines for Flu Serology Appendix 10. LP-093Rev6D - Human Sera Collection Guidelines for Flu Serology.pdf	Form and Instruction
1. GenIC Request Form - EEI Generic ICR KT NML.docx 0920-1011 Emergency GenIC Request Form	IC Document
1. Burden Estimate_EEI Generic ICR 20220001-XXX.docx 0920-1011 - EEI GenIC - Burden Estimate	IC Document
1. Terms of Use - EEI Generic ICR NML.docx 0920-1011 - EEI GenIC Terms of Use	IC Document
CSTE Letter - signed.pdf CSTE Letter of Support - signed	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds â United States, 2022

Agency IC Tracking Number:

0920-1011

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1011	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1011	NA	No		Paper Only
Form and Instruction	0920-1011	NA	No		Paper Only
Form and Instruction	0920-1011	NA	No		Paper Only
Form and Instruction	0920-1011	NA	No		Paper Only
Form and Instruction	0920-1011	NA	No		Paper Only
Form and Instruction	0920-1011	NA	No		Paper Only
Form and Instruction	0920-1011	NA	No		Paper Only
Form and Instruction	0920-1011	NA	No		Paper Only
Form and Instruction	0920-1011	NA	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemic Investigation Case Records - SORN number 09-20-0113

FR Citation: 51 FR 42466

Number of Respondents: 650

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,800	7,800
Annual IC Time Burden (Hours)	199	199
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0920-1011 Emergency GenIC Request Form		04/09/2022
0920-1011 - EEI GenIC - Burden Estimate		04/09/2022
0920-1011 - EEI GenIC Terms of Use		04/09/2022
CSTE Letter of Support - signed		04/09/2022

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

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