Information Collection

HAIC- Multi-Site Gram-Negative Surveillance Initiative (MuGSI) Case Report Form (CFR)

IC 217336 under ICR 202309-0920-002 · OMB 0920-0978.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CS342262-A HAIC- Multi-Site Gram-Negative Surveillance Initiative (MuGSI) Case Report Form (CFR) Form
CS342262-A 2024 Multi-site Gram-Negative Surveillance Initiative (M Att9_HAIC_2024 MuGSI CRF.pdf Form
CS342262-A 2024 Multi-site Gram-Negative Surveillance Initiative (M Att9_HAIC_2024 MuGSI CRF.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HAIC- Multi-Site Gram-Negative Surveillance Initiative (MuGSI) Case Report Form (CFR)	Agency IC Tracking Number:	0920-0978-23HY

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 PHSA

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CS342262-A	2024 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare-Associated Infections Community Interface (HAIC) Case Report	Att9_HAIC_2024 MuGSI CRF.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	47,000	42,000	5,000
Annual IC Time Burden (Hours)	21,933	19,600	2,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.