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

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

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
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[PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN) 0920-0879-24CN
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL 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 pediátrica de etiología desconocida - Cuestionario sobre exposiciones (entrevista a los padres) Att D_Hepatitis pediátrica de etiología desconocida - Cuestionario sobre exposiciones (entrevista a los padres). 8Dec2023.docx Yes Yes Fillable Fileable
Form and Instruction 0920-0879 Hepatitis pediátrica de etiología desconocida. CONTROL del cuestionario sobre exposiciones (Entrevista a los padres) Att E_Hepatitis pediátrica de etiología desconocida CONTROL del uestionario sobre exposiciones_8Dec2023.docx Yes Yes Fillable Fileable

Health Illness Prevention

 

500 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5,000 0 5,000 0 0 0
Annual IC Time Burden (Hours) 375 0 375 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.