Information Collection

[PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN)

IC 264737 under ICR 202306-0920-009 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0879 [PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN)	Form and Instruction
0920-0879 PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL RECORD A Attachment A_Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form Controls_17Jan2024.docx	Form and Instruction
0920-0879 Pediatric Hepatitis of Unknown Etiology - Exposures Ques Attachment B_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire [Parental Interview]_17Jan2024.docx	Form and Instruction
0920-0879 Pediatric Hepatitis of Unknown Etiology - Exposures Ques Attachment C_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire CONTROL [Parental Interview]_17Jan2024.docx	Form and Instruction
0920-0879 Hepatitis pediátrica de etiología desconocida - Cuestion Att D_Hepatitis pediátrica de etiología desconocida - Cuestionario sobre exposiciones (entrevista a los padres). 8Dec2023.docx	Form and Instruction
0920-0879 Hepatitis pediátrica de etiología desconocida. CONTROL d Att E_Hepatitis pediátrica de etiología desconocida CONTROL del uestionario sobre exposiciones_8Dec2023.docx	Form and Instruction
CSTLTS Generic Supporting_Statement_A_Guideline File_17Jan2024.docx SSA	IC Document
CSTLTS Generic Supporting_Statement_B_Guideline File_17Jan2024.docx SSB	IC Document

IC Title:

[PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN)

Agency IC Tracking Number:

0920-0879-24CN

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0879	PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL RECORD ABSTRACTION FORM	Attachment A_Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form Controls_17Jan2024.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0879	Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire (Parental Interview)	Attachment B_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire [Parental Interview]_17Jan2024.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0879	Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire CONTROL (Parental Interview)	Attachment C_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire CONTROL [Parental Interview]_17Jan2024.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0879	Hepatitis pediÃ¡trica de etiologÃa desconocida - Cuestionario sobre exposiciones (entrevista a los padres)	Att D_Hepatitis pediÃ¡trica de etiologÃa desconocida - Cuestionario sobre exposiciones (entrevista a los padres). 8Dec2023.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0879	Hepatitis pediÃ¡trica de etiologÃa desconocida. CONTROL del cuestionario sobre exposiciones (Entrevista a los padres)	Att E_Hepatitis pediÃ¡trica de etiologÃa desconocida CONTROL del uestionario sobre exposiciones_8Dec2023.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

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	5,000	5,000
Annual IC Time Burden (Hours)	375	375
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA	CSTLTS Generic Supporting_Statement_A_Guideline File_17Jan2024.docx	01/26/2024
SSB	CSTLTS Generic Supporting_Statement_B_Guideline File_17Jan2024.docx	01/26/2024

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