[NCEZID] Emerging Infections Program

ICR 202302-0920-009

OMB: 0920-0978

Federal Form Document

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0920-0978 can be found here:

2023-12-29 - No material or nonsubstantive change to a currently approved collection
2023-09-12 - No material or nonsubstantive change to a currently approved collection

Forms and Documents

Document Name	Status
Form 0920-0978 HAIC Death Ascertainment Project Form and Instruction	Unchanged
Form 0920-0978 HAIC Death Ascertainment Project Form and Instruction	Unchanged
Form 0920-0978 HAIC Multi-site Gram-negative Surveillance Initiative (MuGSI) Supplemental Surveillance Officer Survey Form and Instruction	Unchanged
Form 0920-0978 HAIC Multi-site Gram-negative Surveillance Initiative (MuGSI) Supplemental Surveillance Officer Survey Form and Instruction	Unchanged
Form 0920-0978 Community-Associated CP-CRE Interview Form and Instruction	Unchanged
Form 0920-0978 Community-Associated CP-CRE Interview Form and Instruction	Unchanged
Form 0920-0978 HAIC Candidemia Periodic Laboratory Survey Form and Instruction	Modified
Form 0920-0978 HAIC Candidemia Periodic Laboratory Survey Form and Instruction	Modified
Form 0920-0978 HAIC Invasive Staphylococcus aureus Annual Surveillance Officers Survey Form and Instruction	Modified
Form 0920-0978 HAIC Invasive Staphylococcus aureus Annual Surveillance Officers Survey Form and Instruction	Modified
Form 0920-0978 HAIC Invasive Staphylococcus aureus Annual Laboratory Survey Form and Instruction	Modified
Form 0920-0978 HAIC Invasive Staphylococcus aureus Annual Laboratory Survey Form and Instruction	Modified
Form 0920-0978 HAIC CDI LTCF Survey Form and Instruction	Unchanged
Form 0920-0978 HAIC CDI LTCF Survey Form and Instruction	Unchanged
Form 0920-0978 HAIC CDI Annual Surveillance Officers Survey Form and Instruction	Modified
Form 0920-0978 HAIC CDI Annual Surveillance Officers Survey Form and Instruction	Modified
Form 0920-0978 HAIC CDI Annual Laboratory Survey Form and Instruction	Modified
Form 0920-0978 HAIC CDI Annual Laboratory Survey Form and Instruction	Modified
Form 0920-0978 Flu Surv NET Laboratory Survey Form	Modified
Form 0920-0978 Flu Surv NET Laboratory Survey Form	Modified
Form 0920-0978 Foodnet Clinical Laboratory Practices and Testing Volume Form and Instruction	Modified
Form 0920-0978 Foodnet Clinical Laboratory Practices and Testing Volume Form and Instruction	Modified
Form 0920-0978 HAIC Candidemia Case Report Form Form and Instruction	Modified
Form 0920-0978 HAIC Candidemia Case Report Form Form and Instruction	Modified
Form 0920-0978 HAIC Invasive Methicillin-Sensitive Staphylococcus aureus (MSSA) Form and Instruction	Modified
Form 0920-0978 HAIC Invasive Methicillin-Sensitive Staphylococcus aureus (MSSA) Form and Instruction	Modified
Form 0920-0978 HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Form	Modified
Form 0920-0978 HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Form	Modified
Form 0920-0978 Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Form and Instruction	Unchanged
Form 0920-0978 Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Form and Instruction	Unchanged
Form 0920-0978 Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish) Form and Instruction	Unchanged
Form 0920-0978 Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish) Form and Instruction	Unchanged
Form 0920-0978 ABCs Severe GAS Infection Supplemental Form Form and Instruction	Unchanged
Form 0920-0978 ABCs Severe GAS Infection Supplemental Form Form and Instruction	Unchanged
Form 0920-0978 ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form Form and Instruction	Unchanged
Form 0920-0978 ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form Form and Instruction	Unchanged
Form 0920-0978 HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB) Form	Modified
Form 0920-0978 HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB) Form	Modified
Form 0920-0978 HAIC CDI Case Report Form Form and Instruction	Modified
Form 0920-0978 HAIC CDI Case Report Form Form and Instruction	Modified
Form 0920-0978 Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English) Form and Instruction	Unchanged
Form 0920-0978 Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English) Form and Instruction	Unchanged
Form 0920-0978 FoodNet Hemolytic Uremic Syndrome (HUS) Form and Instruction	Modified
Form 0920-0978 FoodNet Hemolytic Uremic Syndrome (HUS) Form and Instruction	Modified
Form 0920-0978 Influenza Hospitalization Surveilance Network Case Report Form Form and Instruction	Modified
Form 0920-0978 Influenza Hospitalization Surveilance Network Case Report Form Form and Instruction	Modified
Form 0920-0978 Active Bacterial Core Surveillance (ABCs) Neonatal Infection Expanded Tracking Form Form and Instruction	Modified
Form 0920-0978 Active Bacterial Core Surveillance (ABCs) Neonatal Infection Expanded Tracking Form Form and Instruction	Modified
Form 0920-0978 ABCs Invasive Pneumococcal Disease in Children Form and Instruction	Unchanged
Form 0920-0978 ABCs Invasive Pneumococcal Disease in Children Form and Instruction	Unchanged
Form 0920-0978 HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Form and Instruction	Modified
Form 0920-0978 HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Form and Instruction	Modified
Form 0920-0978 2023 Active Bacterial Core Surveillance (ABCs) Case Report Form and Instruction	Modified
Form 0920-0978 2023 Active Bacterial Core Surveillance (ABCs) Case Report Form and Instruction	Modified
Att10_COVID-19 Vaccination Status on FluSurv-NET Cases_20220808.pdf Supplementary Document	2023-02-28
Att10_COVID-19 Vaccination Status on FluSurv-NET Cases_20220808.pdf Supplementary Document	2023-02-28
EIP 0920-0978_Non-sub change request_Oct2022FOR2023.docx Justification for No Material/Nonsubstantive Change	2023-02-28
EIP 0920-0978_Non-sub change request_Oct2022FOR2023.docx Justification for No Material/Nonsubstantive Change	2023-02-28
Att1_EIP2023_NonSub_DescriptionChanges_OCT2022.docx Justification for No Material/Nonsubstantive Change	2023-02-28
Att1_EIP2023_NonSub_DescriptionChanges_OCT2022.docx Justification for No Material/Nonsubstantive Change	2023-02-28
Att2_EIP2023_NonSub_Crosswalk_OCT2022.docx Supplementary Document	2023-02-28
Att2_EIP2023_NonSub_Crosswalk_OCT2022.docx Supplementary Document	2023-02-28
Att23- HAIC CA CP-CRE interview project manual.pdf Supplementary Document	2022-04-25
Att23- HAIC CA CP-CRE interview project manual.pdf Supplementary Document	2022-04-25
EIP CDI ICMS PIA Signed 2.pdf Supplementary Document	2022-04-25
EIP CDI ICMS PIA Signed 2.pdf Supplementary Document	2022-04-25
MuGSI PIA Signed.pdf Supplementary Document	2022-04-25
MuGSI PIA Signed.pdf Supplementary Document	2022-04-25
Att2- 60-Day FRN_2022.docx Supplementary Document	2022-04-25
Att2- 60-Day FRN_2022.docx Supplementary Document	2022-04-25
Att1- Authorizing_Regulations_T42_section_241.pdf Supplementary Document	2022-04-25
Att1- Authorizing_Regulations_T42_section_241.pdf Supplementary Document	2022-04-25
SSB_EIP 2022 Revision_04052022.docx Supporting Statement B	2022-04-25
SSB_EIP 2022 Revision_04052022.docx Supporting Statement B	2022-04-25
SSA_EIP 2022 Revision_04212022_SMN_Clean final_Updated_020723_highlighted edits_final OMB_final.docx Supporting Statement A	2023-02-08
SSA_EIP 2022 Revision_04212022_SMN_Clean final_Updated_020723_highlighted edits_final OMB_final.docx Supporting Statement A	2023-02-08

IC Document Collections

IC ID	Document Title	Status
253051	HAIC Death Ascertainment Project Form and Instruction	Unchanged
253051	HAIC Death Ascertainment Project Form and Instruction	Unchanged
253049	HAIC Multi-site Gram-negative Surveillance Initiative (MuGSI) Supplemental Surveillance Officer Survey Form and Instruction	Unchanged
253049	HAIC Multi-site Gram-negative Surveillance Initiative (MuGSI) Supplemental Surveillance Officer Survey Form and Instruction	Unchanged
253048	Community-Associated CP-CRE Interview Form and Instruction	Unchanged
253048	Community-Associated CP-CRE Interview Form and Instruction	Unchanged
235058	HAIC Candidemia Periodic Laboratory Survey Form and Instruction	Modified
235058	HAIC Candidemia Periodic Laboratory Survey Form and Instruction	Modified
235057	HAIC Invasive Staphylococcus aureus Annual Surveillance Officers Survey Form and Instruction	Modified
235057	HAIC Invasive Staphylococcus aureus Annual Surveillance Officers Survey Form and Instruction	Modified
235056	HAIC Invasive Staphylococcus aureus Annual Laboratory Survey Form and Instruction	Modified
235056	HAIC Invasive Staphylococcus aureus Annual Laboratory Survey Form and Instruction	Modified
235055	HAIC CDI LTCF Survey Form and Instruction	Unchanged
235055	HAIC CDI LTCF Survey Form and Instruction	Unchanged
235054	HAIC CDI Annual Surveillance Officers Survey Form and Instruction	Modified
235054	HAIC CDI Annual Surveillance Officers Survey Form and Instruction	Modified
235053	HAIC CDI Annual Laboratory Survey Form and Instruction	Modified
235053	HAIC CDI Annual Laboratory Survey Form and Instruction	Modified
235052	Flu Surv NET Laboratory Survey Form	Modified
235052	Flu Surv NET Laboratory Survey Form	Modified
235051	Foodnet Clinical Laboratory Practices and Testing Volume Form and Instruction	Modified
235051	Foodnet Clinical Laboratory Practices and Testing Volume Form and Instruction	Modified
231114	HAIC Candidemia Case Report Form Form and Instruction	Modified
231114	HAIC Candidemia Case Report Form Form and Instruction	Modified
231113	HAIC Invasive Methicillin-Sensitive Staphylococcus aureus (MSSA) Form and Instruction	Modified
231113	HAIC Invasive Methicillin-Sensitive Staphylococcus aureus (MSSA) Form and Instruction	Modified
231112	HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Form	Modified
231112	HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Form	Modified
231111	Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Form and Instruction	Unchanged
231111	Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Form and Instruction	Unchanged
231110	Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish) Form and Instruction	Unchanged
231110	Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (Spanish) Form and Instruction	Unchanged
230869	ABCs Severe GAS Infection Supplemental Form Form and Instruction	Unchanged
230869	ABCs Severe GAS Infection Supplemental Form Form and Instruction	Unchanged
220380	ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form Form and Instruction	Unchanged
220380	ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form Form and Instruction	Unchanged
217336	HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB) Form	Modified
217336	HAIC Multi-Site Gram-Negative Bacilli Case Report Form (MuGSI-CRE/CRAB) Form	Modified
217334	HAIC CDI Case Report Form Form and Instruction	Modified
217334	HAIC CDI Case Report Form Form and Instruction	Modified
207663	FoodNet Yersinia Other-Variable list	Modified
207662	FoodNet Vibrio Other-Variable list	Modified
207661	FoodNet Shigella Other-Variable list	Modified
207660	FoodNet Shiga toxin producing E. coli Other-Variable list	Modified
207659	FoodNet Salmonella Other-Variable list	Modified
207658	FoodNet Listeria monocytogenes Other-Variable list	Modified
207657	FoodNet Cyclospora Other-Variable list	Modified
207655	FoodNet Campylobacter Other-Variable list	Modified
207653	Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English) Form and Instruction	Unchanged
207653	Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English) Form and Instruction	Unchanged
207652	FoodNet Hemolytic Uremic Syndrome (HUS) Form and Instruction	Modified
207652	FoodNet Hemolytic Uremic Syndrome (HUS) Form and Instruction	Modified
207651	Influenza Hospitalization Surveilance Network Case Report Form Form and Instruction	Modified
207651	Influenza Hospitalization Surveilance Network Case Report Form Form and Instruction	Modified
207649	Active Bacterial Core Surveillance (ABCs) Neonatal Infection Expanded Tracking Form Form and Instruction	Modified
207649	Active Bacterial Core Surveillance (ABCs) Neonatal Infection Expanded Tracking Form Form and Instruction	Modified
207648	ABCs Invasive Pneumococcal Disease in Children Form and Instruction	Unchanged
207648	ABCs Invasive Pneumococcal Disease in Children Form and Instruction	Unchanged
207647	HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Form and Instruction	Modified
207647	HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Form and Instruction	Modified
207646	2023 Active Bacterial Core Surveillance (ABCs) Case Report Form and Instruction	Modified
207646	2023 Active Bacterial Core Surveillance (ABCs) Case Report Form and Instruction	Modified

ICR Details