Chronic Q Fever-Enhanced Surveillance Report Form

Chronic Q Fever in the United States: Enhanced Clinical Surveillance

Documents and Forms

Document Name Document Type
Form 0920-1305 Chronic Q Fever-Enhanced Surveillance Report Form Form
0920-1305 Q Fever Case Report Att 6 Chronic Q fever enhanced surveillance report form.pdf Form
0920-1305 Q Fever Case Report Att 6 Chronic Q fever enhanced surveillance report form.pdf Form
Att 3 NNDSS Q Fever Case Definition.pdf NNDSS Q Fever Case Definition IC Document
Att 3 NNDSS Q Fever Case Definition.pdf NNDSS Q Fever Case Definition IC Document
Att 5 Consent Script.docx Att 5._Consent Script for Survey IC Document
Att 5 Consent Script.docx Att 5._Consent Script for Survey IC Document
Att 4 Supplemental Q Fever Case Report Form.pdf Supplemental Q Fever Case Report Form (CFR) IC Document
Att 4 Supplemental Q Fever Case Report Form.pdf Supplemental Q Fever Case Report Form (CFR) IC Document

Information Collection (IC) Details

IC Title:	Chronic Q Fever-Enhanced Surveillance Report Form	Agency IC Tracking Number:	0920-1305

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-1305	Q Fever Case Report	Att 6 Chronic Q fever enhanced surveillance report form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	50	35	15
Annual IC Time Burden (Hours)	17	12	5
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
NNDSS Q Fever Case Definition	Att 3 NNDSS Q Fever Case Definition.pdf	09/13/2023
Att 5._Consent Script for Survey	Att 5 Consent Script.docx	09/13/2023
Supplemental Q Fever Case Report Form (CFR)	Att 4 Supplemental Q Fever Case Report Form.pdf	09/13/2023

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