Information Collection

Consent for Linkage to Reportable Infectious Diseases Results

IC 216974 under ICR 202212-0920-015 · OMB 0920-0010.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0010 can be found here:

2025-05-01 - No material or nonsubstantive change to a currently approved collection
2024-05-07 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Consent for Linkage to Reportable Infectious Diseases Results	Form and Instruction
Written Consent for Release of Reportable Infectious Diseases (English) Consent for Linkage to Reportable Infectious Diseases Results	Form and Instruction
Written Consent for Release of Reportable Infectious Diseases (Spanish) Consent for Linkage to Reportable Infectious Diseases Results	Form and Instruction
Verbal Consent for Release of Reportable Infectious Diseases (English) Consent for Linkage to Reportable Infectious Diseases Results	Form and Instruction
Verbal Consent for Release of Reportable Infectious Diseases (Spanish) Consent for Linkage to Reportable Infectious Diseases Results	Form and Instruction
Written Consent for Release of Reportable Infectious Dis AttD2a_Infection_Written_Consent_final.docx	Form and Instruction
Written Consent for Release of Reportable Infectious Dis AttD2a_Infection_Written_Consent_final.docx	Form and Instruction
Written Consent for Release of Reportable Infectious Dis AttD2b_Infection_Written_Consent_final.docx	Form and Instruction
Written Consent for Release of Reportable Infectious Dis AttD2b_Infection_Written_Consent_final.docx	Form and Instruction
Verbal Consent for Release of Reportable Infectious Dise AttD3a_Infection_Verbal_Consent_final.docx	Form and Instruction
Verbal Consent for Release of Reportable Infectious Dise AttD3a_Infection_Verbal_Consent_final.docx	Form and Instruction
Verbal Consent for Release of Reportable Infectious Dise AttD3b_Infection_Verbal_Consent_final.docx	Form and Instruction
Verbal Consent for Release of Reportable Infectious Dise AttD3b_Infection_Verbal_Consent_final.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Consent for Linkage to Reportable Infectious Diseases Results

Agency IC Tracking Number:

0920-0010

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?	Electronic Capability
Form and Instruction	n/a	Written Consent for Release of Reportable Infectious Diseases (English)	AttD2a_Infection_Written_Consent_final.docx	No	Paper Only
Form and Instruction	n/a	Written Consent for Release of Reportable Infectious Diseases (Spanish)	AttD2b_Infection_Written_Consent_final.docx	No	Paper Only
Form and Instruction	n/a	Verbal Consent for Release of Reportable Infectious Diseases (English)	AttD3a_Infection_Verbal_Consent_final.docx	No	Paper Only
Form and Instruction	n/a	Verbal Consent for Release of Reportable Infectious Diseases (Spanish)	AttD3b_Infection_Verbal_Consent_final.docx	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 2,590

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,590	0	2,590
Annual IC Time Burden (Hours)	648	0	648
Annual IC Cost Burden (Dollars)	0	-6,475	6,475

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.