Att D-4_Acute Flaccid Myelitis

National Disease Surveillance Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0009 can be found here:

Documents and Forms

Document Name Document Type
Att D-4_Acute Flaccid Myelitis Form and Instruction
Acute Flaccid Myelitis Patient Summary Form AFM-patient-summary-form-update (clean).docx Form and Instruction
Acute Flaccid Myelitis Patient Summary Form AFM-patient-summary-form-update (clean).docx Form and Instruction
0920-0009 Acute Flaccid Myelitis: Patient Summary Form patient-summary-form clean copy 5.3.2022.docx Form and Instruction
0920-0009 Acute Flaccid Myelitis: Patient Summary Form patient-summary-form clean copy 5.3.2022.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Att D-4_Acute Flaccid Myelitis	Agency IC Tracking Number:	17AXX

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Acute Flaccid Myelitis Patient Summary Form	AFM-patient-summary-form-update (clean).docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0009	Acute Flaccid Myelitis: Patient Summary Form	patient-summary-form clean copy 5.3.2022.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.