Information Collection Request

Maritime Illness Database and Reporting System (MIDRS)

ICR 202204-0920-002 · OMB 0920-1260 · Received in OIRA

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 0920-1260 Recordkeeping of Engineering and Sanitation Records Form and Instruction New Repair queued
Form 0920-1260 (Passenger) 72-hour Food/Activity History Template (AGE cases) Form and Instruction New Repair queued
Form 0920-1260 Last Symptom Check and Return to Work Clearance (food and nonfood employees) Form and Instruction New Repair queued
Form 0920-1260 Interviews to Determine AGE Status (initial, 24-hr, 48-hr)(asymptomatic cabin mates and immediate contacts of symptomatic crew) Form and Instruction New Missing upstream
Form 0920-1260 Three-day Pre-embarkation AGE Illness Assessment (all crew members) Form and Instruction New Repair queued
Form 0920-1260 (CREW) 72-hour Food/Activity History Template (AGE cases) Form and Instruction New Repair queued
Form 0920-1260 Recordkeeping of AGE Surveillance Records Form and Instruction New Repair queued
Form 0920-1260 Daily Reports of AGE Logs Form and Instruction New Repair queued
Form 092-1260 Special Reports exceeding 2%-3% AGE Threshold (web/phone/email/fax) Form and Instruction New Repair queued
Form 0920-1260 AGE Illness Report 4 hours before arrival (phone/email/fax) Form and Instruction New Repair queued
Form 0920-1260 AGE Illness Report 4 hours before arrival (web) Form and Instruction New Available
Form 0920-1260 AGE Illness Report 24 hours before arrival (phone/email/fax) Form and Instruction New Repair queued
Form 0920-1260 AGE Illness Report 24 hours before arrival (web) Form and Instruction New Repair queued
71.21 (c) 72-hour food/activity history - AGE Passenger and Crew cases Form and Instruction Removed Repair queued
71.21 (c) Recordkeeping - medical records (72-hour food/activity history) Form and Instruction Removed Available
71.21 (c) Recordkeeping – medical records (Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees) Form and Instruction Removed Repair queued
71.21 (c) Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees Form and Instruction Removed Repair queued
71.21(c) Recordkeeping - medical records (Documentation of 3-day pre-embarkation AGE illness assessment for all crew members) Form and Instruction Removed Repair queued
71.21 (c) Documentation of 3-day pre-embarkation AGE illness assessment for all crew members Form and Instruction Removed Repair queued
71.21 (c) Recordkeeping – medical records (Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times) Form and Instruction Removed Repair queued
71.21 (c) Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times Form and Instruction Removed Available
71.21 (c) Recordkeeping – medical records (AGE Logs) Form and Instruction Removed Repair queued
71.21 (c) AGE Logs Form and Instruction Removed Repair queued
71.21(c) Recordkeeping - Gastrointestinal Illnesses Report 24 and 4 hours before arrival Form and Instruction Removed Repair queued
71.21(c) Gastrointestinal Illness Report - 24 and 4 hours before arrival (MIDRS) Form and Instruction Removed Available
Att8 IntlConventionofSafetyofLifeatSea.pdf Supplementary Document Uploaded 2022-04-04 Missing upstream
Att7 ResearchDeterminationForm 20210916.pdf Supplementary Document Uploaded 2022-04-04 Repair queued
1 - VSP MIDRS Revision List Attachments 20220125.docx Supplementary Document Uploaded 2022-04-04 Repair queued
Att4b.VSP2018OperationsManual.pdf Supplementary Document Uploaded 2022-04-04 Repair queued
Att4a.42CFR71.1bii.pdf Supplementary Document Uploaded 2022-04-04 Repair queued
Att3b. 1987FRN_VSPfromDGMQtoNCEH.pdf Supplementary Document Uploaded 2022-04-04 Repair queued
Att3a.1985FRN_VSPinDGMQ.pdf Supplementary Document Uploaded 2022-04-04 Repair queued
Att2. MIDRS_60D_FRN.pdf Supplementary Document Uploaded 2022-04-04 Repair queued
Att1c. 42CFRPart71 -- Foreign Quarantine.pdf Supplementary Document Uploaded 2022-04-04 Repair queued
Att1b.42USCSection269.pdf Supplementary Document Uploaded 2022-04-04 Repair queued
Att1a. 42USCSection264.pdf Supplementary Document Uploaded 2022-04-04 Repair queued
0 - Privacy Act Checklist MIDRS Rev 20220125.docx Supplementary Document Uploaded 2022-04-04 Repair queued
Att10.PIA.pdf Supplementary Document Uploaded 2019-02-21 Repair queued
Att9.IntlConventionofSafetyofLifeatSea.pdf Supplementary Document Uploaded 2019-02-21 Available
Att6.ResearchDeterminationForm.pdf Supplementary Document Uploaded 2019-02-21 Available
Att4b.VSP2018OperationsManual.pdf Supplementary Document Uploaded 2019-02-21 Repair queued
Att3b. 1987FRN_VSPfromDGMQtoNCEH.pdf Supplementary Document Uploaded 2019-02-20 Repair queued
Att3a.1985FRN_VSPinDGMQ.pdf Supplementary Document Uploaded 2019-02-20 Repair queued
Att2.60dayFRN.pdf Supplementary Document Uploaded 2019-02-20 Repair queued
Att1c. 42CFRPart71.pdf Supplementary Document Uploaded 2019-02-20 Repair queued
Att1b.42USCSection269.pdf Supplementary Document Uploaded 2019-02-20 Repair queued
Att1a. 42USCSection264.pdf Supplementary Document Uploaded 2019-02-20 Repair queued
1 - SSB_MIDRS Revision 20220125.docx Supporting Statement B Uploaded 2022-04-04 Repair queued
1 - SSA_MIDRS Revision 202200404 v2.docx Supporting Statement A Uploaded 2022-04-04 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
252608 Recordkeeping of Engineering and Sanitation Records Form and Instruction New
252607 (Passenger) 72-hour Food/Activity History Template (AGE cases) Form and Instruction New
252606 Last Symptom Check and Return to Work Clearance (food and nonfood employees) Form and Instruction New
252605 Interviews to Determine AGE Status (initial, 24-hr, 48-hr)(asymptomatic cabin mates and immediate contacts of symptomatic crew) Form and Instruction New
252603 Three-day Pre-embarkation AGE Illness Assessment (all crew members) Form and Instruction New
252602 (CREW) 72-hour Food/Activity History Template (AGE cases) Form and Instruction New
252599 Recordkeeping of AGE Surveillance Records Form and Instruction New
252598 Daily Reports of AGE Logs Form and Instruction New
252597 Special Reports exceeding 2%-3% AGE Threshold (web/phone/email/fax) Form and Instruction New
252596 AGE Illness Report 4 hours before arrival (phone/email/fax) Form and Instruction New
252595 AGE Illness Report 4 hours before arrival (web) Form and Instruction New
252594 AGE Illness Report 24 hours before arrival (phone/email/fax) Form and Instruction New
252593 AGE Illness Report 24 hours before arrival (web) Form and Instruction New
235080 71.21 (c) 72-hour food/activity history - AGE Passenger and Crew cases Form and Instruction Removed
235079 71.21 (c) Recordkeeping - medical records (72-hour food/activity history) Form and Instruction Removed
235078 71.21 (c) Recordkeeping – medical records (Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees) Form and Instruction Removed
235077 71.21 (c) Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees Form and Instruction Removed
235076 71.21(c) Recordkeeping - medical records (Documentation of 3-day pre-embarkation AGE illness assessment for all crew members) Form and Instruction Removed
235075 71.21 (c) Documentation of 3-day pre-embarkation AGE illness assessment for all crew members Form and Instruction Removed
235074 71.21 (c) Recordkeeping – medical records (Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times) Form and Instruction Removed
235073 71.21 (c) Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times Form and Instruction Removed
235072 71.21 (c) Recordkeeping – medical records (AGE Logs) Form and Instruction Removed
235071 71.21 (c) AGE Logs Form and Instruction Removed
235070 71.21(c) Recordkeeping - Gastrointestinal Illnesses Report 24 and 4 hours before arrival Form and Instruction Removed
235047 71.21(c) Gastrointestinal Illness Report - 24 and 4 hours before arrival (MIDRS) Form and Instruction Removed

ICR Details

Reginfo record details
table that charts list comparision
  Requested Previously Approved
36 Months From Approved 04/30/2022
10,109,580 13,750
5,782,228 1,538
0 0





Reginfo record details
13
table that charts list of burden
IC Title Form No. Form Name
(CREW) 72-hour Food/Activity History Template (AGE cases) 0920-1260 72-hour Food/Activity History Template (AGE cases)
(Passenger) 72-hour Food/Activity History Template (AGE cases) 0920-1260 72-hour Food/Activity History Template (AGE cases)
71.21 (c) 72-hour food/activity history - AGE Passenger and Crew cases NA 72-hr Food/Activity History Template
71.21 (c) AGE Logs NA VSP AGE Log
71.21 (c) Documentation of 3-day pre-embarkation AGE illness assessment for all crew members NA Documentation of 3-day pre-embarkation AGE illness assessment
71.21 (c) Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees NA Documentation of Last Symptom and Clearance to Return to Work
71.21 (c) Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times NA Documentation of Interviews with AGE Crew Case Cabin Mates and Immediate Contacts to Determine AGE Illness Status
71.21 (c) Recordkeeping - medical records (72-hour food/activity history) NA Gastrointestinal Illness Surveillance System Questionnaire
71.21 (c) Recordkeeping – medical records (AGE Logs) NA VSP AGE Log
71.21 (c) Recordkeeping – medical records (Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees) NA Documentation of Last Symptom and Clearance to Return to Work
71.21 (c) Recordkeeping – medical records (Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times) NA Documentation of Interviews with AGE Crew Case Cabin Mates and Immediate Contacts to Determine AGE Illness Status
71.21(c) Gastrointestinal Illness Report - 24 and 4 hours before arrival (MIDRS) NA, NA Gastrointestinal Illness (GI) Template ,   MIDRS Template - screenshot
71.21(c) Recordkeeping - Gastrointestinal Illnesses Report 24 and 4 hours before arrival NA Recordkeeping - MIDRS Template
71.21(c) Recordkeeping - medical records (Documentation of 3-day pre-embarkation AGE illness assessment for all crew members) NA Documentation of 3-day pre-embarkation AGE illness assessment
AGE Illness Report 24 hours before arrival (phone/email/fax) 0920-1260 AGE Illness Report 24 hours before arrival (phone/email/fax)
AGE Illness Report 24 hours before arrival (web) 0920-1260 AGE Illness Report 24 hours before arrival (web)
AGE Illness Report 4 hours before arrival (phone/email/fax) 0920-1260 Att5a2 4 hr AGEIllnssRprt (phone email fax) 20220125
AGE Illness Report 4 hours before arrival (web) 0920-1260 AGE Illness Report 4 hours before arrival (web)
Daily Reports of AGE Logs 0920-1260 Daily Reports of AGE Logs
Interviews to Determine AGE Status (initial, 24-hr, 48-hr)(asymptomatic cabin mates and immediate contacts of symptomatic crew) 0920-1260 Interviews to Determine AGE Status (initial, 24-hr, 48-hr)(asymptomatic cabin mates and immediate contacts of symptomatic crew)
Last Symptom Check and Return to Work Clearance (food and nonfood employees) 0920-1260 Last Symptom Check and Return to Work Clearance (food and nonfood employees)
Recordkeeping of AGE Surveillance Records 0920-1260 Recordkeeping of AGE Surveillance Records
Recordkeeping of Engineering and Sanitation Records 0920-1260 Recordkeeping of Engineering and Sanitation Records
Special Reports exceeding 2%-3% AGE Threshold (web/phone/email/fax) 092-1260 Special Reports exceeding 2%-3% AGE Threshold (web/phone/email/fax)
Three-day Pre-embarkation AGE Illness Assessment (all crew members) 0920-1260 Three-day Pre-embarkation AGE Illness Assessment (all crew members)

table that charts list of burden
  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 10,109,580 13,750 0 10,081,830 14,000 0
Annual Time Burden (Hours) 5,782,228 1,538 0 5,778,244 2,446 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No