Information Collection

Freely Associated States - One-time Addition of Diseases and Data Elements

IC 235861 under ICR 202205-0920-002 · OMB 0920-0728.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0728 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0728 Disease-Specific Data Freely Associated States - One-time Addition of Diseases and Data Elements	Form and Instruction
Att 5 - Core Data.xlsx	Instruction
Att 5 - Core Data.xlsx	Instruction
Att 6 - Laboratory Data.xlsx	Instruction
Att 6 - Laboratory Data.xlsx	Instruction
Att 8 - Vaccine Data.xlsx	Instruction
Att 8 - Vaccine Data.xlsx	Instruction
Att 8 - VPD Data.xlsx	Instruction
Att 8 - VPD Data.xlsx	Instruction
0920-0728 Disease-Specific Data Att 10 - Disease-Specific Data.xlsx	Form and Instruction
0920-0728 Disease-Specific Data Att 10 - Disease-Specific Data.xlsx	Form and Instruction
Att 9 - Justification for Disease-Specific Data.pdf Justification for Disease-Specific Data	IC Document
Att 9 - Justification for Disease-Specific Data.pdf Justification for Disease-Specific Data	IC Document
Att 15 - PRA Burden Statement Screenshot.pdf PRA Burden Statement (screenshot)	IC Document
Att 15 - PRA Burden Statement Screenshot.pdf PRA Burden Statement (screenshot)	IC Document

IC Title:

Freely Associated States - One-time Addition of Diseases and Data Elements

Agency IC Tracking Number:

0920-0728

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Att 5 - Core Data.xlsx	Yes	Yes	Fillable Fileable
Instruction			Att 6 - Laboratory Data.xlsx	Yes	Yes	Fillable Fileable
Instruction			Att 8 - Vaccine Data.xlsx	Yes	Yes	Fillable Fileable
Instruction			Att 8 - VPD Data.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0728	Disease-Specific Data	Att 10 - Disease-Specific Data.xlsx	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 76 FR 4458

Number of Respondents: 3

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3	0	3
Annual IC Time Burden (Hours)	3	-45	48
Annual IC Cost Burden (Dollars)	2,080	0	2,080

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification for Disease-Specific Data	Att 9 - Justification for Disease-Specific Data.pdf	05/16/2022
PRA Burden Statement (screenshot)	Att 15 - PRA Burden Statement Screenshot.pdf	05/16/2022

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