Information Collection Request

Emergency Epidemic Investigation Data Collections

ICR 202209-0920-030 · OMB 0920-1011 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 0920-1011 CDC Case Report Form: Serious Adverse Events Following Ceftriaxone Injection in Healthcare Settings Form and Instruction New Repair queued
Form 0920-1011 Case Report Form - Ceftriaxone Injection in Healthcare Settings - Healthcare Providers Form and Instruction New Repair queued
Form 0920-1011 Case Report Form - Ceftriaxone Injection in Healthcare Settings - Public Health Departments Form and Instruction New Repair queued
Case Report Form Form and Instruction New Repair queued
Form 0920-1011 Case Report Form - (CP-CRE) among Children in U.S. Healthcare Settings Form and Instruction New Repair queued
Form 0920-1011 Diamond Shruumz Outbreak Investigation Case Report Form Form and Instruction New Repair queued
Form 0920-1011 VIM-CRPA Outbreak Chart Abstraction Form] Form and Instruction New Repair queued
Form 0920-1011 Facility Product List Form New Available
Form 0920-1011 Chart Abstraction Form Form New Available
Published 30dy221011.pdf Supplementary Document Uploaded 2022-09-29 Repair queued
EEI GenICR_Sup St A_10.03.22.docx Supporting Statement A Uploaded 2022-10-03 Repair queued
EEI GenICR_Sup St B.docx Supporting Statement B Uploaded 2022-09-29 Repair queued
App 6_Online Survey Case Finding Questionnaire.docx Supplementary Document Uploaded 2022-09-29 Repair queued
App 5_Phone Interview Questionnaire Patient.docx Supplementary Document Uploaded 2022-09-29 Repair queued
App 4_Q Fever Person Interview Questionnaire.docx Supplementary Document Uploaded 2022-09-29 Repair queued
App 3 _Hantav Pulm Synd Questionnaire.docx Supplementary Document Uploaded 2022-09-29 Repair queued
App 2_GBS Case Questionnaire.docx Supplementary Document Uploaded 2022-09-29 Repair queued
App 1_Chart Abstract Form.docx Supplementary Document Uploaded 2022-09-29 Repair queued
Attach H_Biospecimen Storage Consent.docx Supplementary Document Uploaded 2022-09-29 Repair queued
Attach G_Emer Epi Invest_IRB Letter.pdf Supplementary Document Uploaded 2022-09-29 Repair queued
Attach F_Epi Invest SORN.docx Supplementary Document Uploaded 2022-09-29 Repair queued
Attach E_Burden Memo.docx Supplementary Document Uploaded 2022-09-29 Repair queued
Attach D_GenIC Request Form for Emergency Epidemic Investigation.docx Supplementary Document Uploaded 2022-09-29 Repair queued
Attach C_ Steps Conduct Emer Epi Invest.docx Supplementary Document Uploaded 2022-09-29 Repair queued
Attach B_EEI Extension 60 Day FRN.pdf Supplementary Document Uploaded 2022-09-29 Repair queued
EEI GenICR_0920-13ZJ_Attach A_Auth Legis Emer Epi Invest_11-06-2013_Subm.pdf Supplementary Document Uploaded 2013-11-20 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
275252 Serious adverse events, including deaths, of unknown etiology following ceftriaxone administration among patients in multiple healthcare facility types, AL and multiple states, September 2024-Present Form and Instruction NewCDC Case Report Form: Serious Adverse Events Following Ceftriaxone Injection in Healthcare Settings
274026 [NCEZID] Multistate investigation of serious adverse events, including deaths, of unknown etiology following ceftriaxone administration_Sep 2024-Present Form and Instruction NewCase Report Form - Ceftriaxone Injection in Healthcare Settings - Healthcare Providers
274026 [NCEZID] Multistate investigation of serious adverse events, including deaths, of unknown etiology following ceftriaxone administration_Sep 2024-Present Form and Instruction NewCase Report Form - Ceftriaxone Injection in Healthcare Settings - Public Health Departments
272438 [NCEZID] Undetermined Risk Ractors for Carbapenemase-producing Carbapenem-resistant Enterobacterales (CP-CRE) Among Children in Healthcare Settings - United States Form and Instruction NewCase Report Form
270183 [NCEZID] Undetermined Risk Factors for carbapenemase-producing carbapenem-resistant Enterobacterales (CP-CRE) among Children in Healthcare Settings Form and Instruction NewCase Report Form - (CP-CRE) among Children in U.S. Healthcare Settings
269133 Investigation of Multistate Outbreak of Severe Illness related to consumption of Diamond ShruumzTM Brand products-United States_2024 Form and Instruction NewDiamond Shruumz Outbreak Investigation Case Report Form
259529 Post-product recall investigation of a multistate cluster of VIM-producing carbapenem resistant Pseudomonas aeruginosa associated with artificial tear use Form and Instruction NewVIM-CRPA Outbreak Chart Abstraction Form]
257566 VIM-Carbapenem Resistant Pseudomonas aeruginosa (VIM-CRPA) Outbreak Investigation Abstraction Form Form NewFacility Product List
257566 VIM-Carbapenem Resistant Pseudomonas aeruginosa (VIM-CRPA) Outbreak Investigation Abstraction Form Form NewChart Abstraction Form

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
12/31/2025 36 Months From Approved 01/31/2023
12,000 0 805,759
6,000 0 402,874
0 0 0





Reginfo record details
7
table that charts list of burden
IC Title Form No. Form Name
Investigation of Multistate Outbreak of Severe Illness related to consumption of Diamond ShruumzTM Brand products-United States_2024 0920-1011
Post-product recall investigation of a multistate cluster of VIM-producing carbapenem resistant Pseudomonas aeruginosa associated with artificial tear use 0920-1011
Serious adverse events, including deaths, of unknown etiology following ceftriaxone administration among patients in multiple healthcare facility types, AL and multiple states, September 2024-Present 0920-1011
VIM-Carbapenem Resistant Pseudomonas aeruginosa (VIM-CRPA) Outbreak Investigation Abstraction Form 0920-1011, 0920-1011 ,  
[NCEZID] Multistate investigation of serious adverse events, including deaths, of unknown etiology following ceftriaxone administration_Sep 2024-Present 0920-1011, 0920-1011 ,  
[NCEZID] Undetermined Risk Factors for carbapenemase-producing carbapenem-resistant Enterobacterales (CP-CRE) among Children in Healthcare Settings 0920-1011
[NCEZID] Undetermined Risk Ractors for Carbapenemase-producing Carbapenem-resistant Enterobacterales (CP-CRE) Among Children in Healthcare Settings - United States n/a

table that charts list of burden
  Total Approved 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 12,000 805,759 0 -793,759 0 0
Annual Time Burden (Hours) 6,000 402,874 0 -396,874 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No