Information Collection

Case Report Form

IC 254011 under ICR 202205-0920-013 · OMB 0920-1385.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1385 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-22BG Case Report Form	Form and Instruction
0920-22BG Case Report Form Att 3 Case Report Form.pdf	Form and Instruction
0920-22BG Case Report Form Att 3 Case Report Form.pdf	Form and Instruction
CRF azole-R AFumigatus 11_15_21.docx Case Report Form - Word	IC Document
CRF azole-R AFumigatus 11_15_21.docx Case Report Form - Word	IC Document

IC Title:

Case Report Form

Agency IC Tracking Number:

0920-22BG

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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	0920-22BG	Case Report Form	Att 3 Case Report Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

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
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Case Report Form - Word	CRF azole-R AFumigatus 11_15_21.docx	06/06/2022

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