Information Collection

Influenza Hospitalization Surveilance Network Case Report Form

IC 207651 under ICR 202204-0920-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Influenza Hospitalization Surveilance Network Case Report Form	Form and Instruction
Influenza Hospitalization Surveillance Network Case Repo Att11- FluSurv-NET CRF_Final_20210831.pdf	Form and Instruction
Influenza Hospitalization Surveillance Network Case Repo Att11- FluSurv-NET CRF_Final_20210831.pdf	Form and Instruction

IC Title:

Influenza Hospitalization Surveilance Network Case Report Form

Agency IC Tracking Number:

0920-0978

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

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	none	Influenza Hospitalization Surveillance Network Case Report	Att11- FluSurv-NET CRF_Final_20210831.pdf		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	9,770	9,770
Annual IC Time Burden (Hours)	3,183	3,183
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.