[NCEZID] Emerging Infections Program

ICR 202312-0920-011

OMB: 0920-0978

Federal Form Document

⚠️ Notice: This information collection may be outdated.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

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 HAIC MuGSI CA CP-CRE Health interview Form and Instruction	Modified
Form 0920-0978 HAIC MuGSI CA CP-CRE Health interview Form and Instruction	Modified
Form 2024 HAIC- Laboratory Testing Practices for Candidemia Questionnaire Form and Instruction	Modified
Form 2024 HAIC- Laboratory Testing Practices for Candidemia Questionnaire Form and Instruction	Modified
Form 0920-0978 HAIC Invasive Staphylococcus aureus Annual Surveillance Officers Survey Form and Instruction	Unchanged
Form 0920-0978 HAIC Invasive Staphylococcus aureus Annual Surveillance Officers Survey Form and Instruction	Unchanged
Form 0920-0978 HAIC Invasive Staphylococcus aureus Annual Laboratory Survey Form and Instruction	Unchanged
Form 0920-0978 HAIC Invasive Staphylococcus aureus Annual Laboratory Survey Form and Instruction	Unchanged
Form 0920-0978 HAIC- EIP C. difficile Surveillance Nursing Home Telephone Survey (LTCF) Form and Instruction	Modified
Form 0920-0978 HAIC- EIP C. difficile Surveillance Nursing Home Telephone Survey (LTCF) Form and Instruction	Modified
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- Annual Survey of Laboratory Testing Practices for C. difficile Infections Form and Instruction	Modified
Form 0920-0978 HAIC- Annual Survey of Laboratory Testing Practices for C. difficile Infections Form and Instruction	Modified
Form CS341327-A 7/31/20 Flu Surv NET Laboratory Survey Form	Modified
Form CS341327-A 7/31/20 Flu Surv NET Laboratory Survey Form	Modified
Form Short Form 2024 HAIC Candidemia Case Report Form Form and Instruction	Modified
Form Short Form 2024 HAIC Candidemia Case Report Form Form and Instruction	Modified
Form CDC 52.15B Rev.07- HAIC Invasive Staphylococcus aureus Case Report – 2024 Form and Instruction	Modified
Form CDC 52.15B Rev.07- HAIC Invasive Staphylococcus aureus Case Report – 2024 Form and Instruction	Modified
Form 0920-0978 HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Form	Removed
Form 0920-0978 HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Form	Removed
Form 0920-0978-24BX FluSurv-Net Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Form and Instruction	Modified
Form 0920-0978-24BX FluSurv-Net Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Form and Instruction	Modified
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 CS342262-A 9/20/20 HAIC Multi-Site Gram-Negative Surveillance Initiative (MUGSI) Case Report Form Form	Modified
Form CS342262-A 9/20/20 HAIC Multi-Site Gram-Negative Surveillance Initiative (MUGSI) Case Report Form Form	Modified
Form CS 342179-A 8/3/20 HAIC - CDI Case Report and Treatment Form Form and Instruction	Modified
Form CS 342179-A 8/3/20 HAIC - CDI Case Report and Treatment Form Form and Instruction	Modified
Form 0920-0978-24BX FluSurv-Net Influenza Hospitalization Surveillance Project Vaccination Phone Script and Consent Form (English/Spanish) Form and Instruction	Modified
Form 0920-0978-24BX FluSurv-Net Influenza Hospitalization Surveillance Project Vaccination Phone Script and Consent Form (English/Spanish) Form and Instruction	Modified
Form 0920-0978 FoodNet Hemolytic Uremic Syndrome (HUS) Form and Instruction	Unchanged
Form 0920-0978 FoodNet Hemolytic Uremic Syndrome (HUS) Form and Instruction	Unchanged
Form CS340190-A FluSurv-Net Influenza Hospitalization Surveillance Network Case Report Form Form and Instruction	Modified
Form CS340190-A FluSurv-Net Influenza Hospitalization Surveillance Network Case Report Form Form and Instruction	Modified
Form 0920-0978 Active Bacterial Core Surveillance (ABCs) Neonatal Infection Expanded Tracking Form Form and Instruction	Unchanged
Form 0920-0978 Active Bacterial Core Surveillance (ABCs) Neonatal Infection Expanded Tracking Form Form and Instruction	Unchanged
Form CDC 52.15A REV.8-2 ABCs Invasive Pneumococcal Disease in Children and Adults Form and Instruction	Modified
Form CDC 52.15A REV.8-2 ABCs Invasive Pneumococcal Disease in Children and Adults Form and Instruction	Modified
Form 0920-0978 HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Form and Instruction	Removed
Form 0920-0978 HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Form and Instruction	Removed
Form CDC 52.12A REV 201 2024 Active Bacterial Core Surveillance (ABCs) Case Report Form and Instruction	Modified
Form CDC 52.12A REV 201 2024 Active Bacterial Core Surveillance (ABCs) Case Report Form and Instruction	Modified
Att2_EIP2024_NonSub_Crosswalk_Dec21.docx Supplementary Document	2023-12-28
Att2_EIP2024_NonSub_Crosswalk_Dec21.docx Supplementary Document	2023-12-28
Att1_EIP2024_NonSub_DescriptionChanges_Dec21.docx Supplementary Document	2023-12-28
Att1_EIP2024_NonSub_DescriptionChanges_Dec21.docx Supplementary Document	2023-12-28
EIP 0920-0978_Non-sub change request.docx Justification for No Material/Nonsubstantive Change	2023-12-28
EIP 0920-0978_Non-sub change request.docx Justification for No Material/Nonsubstantive Change	2023-12-28
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	HAIC MuGSI CA CP-CRE Health interview Form and Instruction	Modified
253048	HAIC MuGSI CA CP-CRE Health interview Form and Instruction	Modified
235058	HAIC- Laboratory Testing Practices for Candidemia Questionnaire Form and Instruction	Modified
235058	HAIC- Laboratory Testing Practices for Candidemia Questionnaire Form and Instruction	Modified
235057	HAIC Invasive Staphylococcus aureus Annual Surveillance Officers Survey Form and Instruction	Unchanged
235057	HAIC Invasive Staphylococcus aureus Annual Surveillance Officers Survey Form and Instruction	Unchanged
235056	HAIC Invasive Staphylococcus aureus Annual Laboratory Survey Form and Instruction	Unchanged
235056	HAIC Invasive Staphylococcus aureus Annual Laboratory Survey Form and Instruction	Unchanged
235055	HAIC- EIP C. difficile Surveillance Nursing Home Telephone Survey (LTCF) Form and Instruction	Modified
235055	HAIC- EIP C. difficile Surveillance Nursing Home Telephone Survey (LTCF) Form and Instruction	Modified
235054	HAIC- CDI Annual Surveillance Officers Survey Form and Instruction	Modified
235054	HAIC- CDI Annual Surveillance Officers Survey Form and Instruction	Modified
235053	HAIC- Annual Survey of Laboratory Testing Practices for C. difficile Infections Form and Instruction	Modified
235053	HAIC- Annual Survey of Laboratory Testing Practices for C. difficile Infections 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 Other-Variable List 2024	Modified
231114	HAIC Candidemia Case Report Form Form and Instruction	Modified
231114	HAIC Candidemia Case Report Form Form and Instruction	Modified
231113	HAIC Invasive Staphylococcus aureus Case Report – 2024 Form and Instruction	Modified
231113	HAIC Invasive Staphylococcus aureus Case Report – 2024 Form and Instruction	Modified
231112	HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Form	Removed
231112	HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL) Form	Removed
231111	FluSurv-Net Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Form and Instruction	Modified
231111	FluSurv-Net Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) Form and Instruction	Modified
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 Surveillance Initiative (MUGSI) Case Report Form Form	Modified
217336	HAIC Multi-Site Gram-Negative Surveillance Initiative (MUGSI) Case Report Form Form	Modified
217334	HAIC - CDI Case Report and Treatment Form Form and Instruction	Modified
217334	HAIC - CDI Case Report and Treatment 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	FluSurv-Net Influenza Hospitalization Surveillance Project Vaccination Phone Script and Consent Form (English/Spanish) Form and Instruction	Modified
207653	FluSurv-Net Influenza Hospitalization Surveillance Project Vaccination Phone Script and Consent Form (English/Spanish) Form and Instruction	Modified
207652	FoodNet Hemolytic Uremic Syndrome (HUS) Form and Instruction	Unchanged
207652	FoodNet Hemolytic Uremic Syndrome (HUS) Form and Instruction	Unchanged
207651	FluSurv-Net Influenza Hospitalization Surveillance Network Case Report Form Form and Instruction	Modified
207651	FluSurv-Net Influenza Hospitalization Surveillance Network Case Report Form Form and Instruction	Modified
207649	Active Bacterial Core Surveillance (ABCs) Neonatal Infection Expanded Tracking Form Form and Instruction	Unchanged
207649	Active Bacterial Core Surveillance (ABCs) Neonatal Infection Expanded Tracking Form Form and Instruction	Unchanged
207648	ABCs Invasive Pneumococcal Disease in Children and Adults Form and Instruction	Modified
207648	ABCs Invasive Pneumococcal Disease in Children and Adults Form and Instruction	Modified
207647	HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Form and Instruction	Removed
207647	HAIC Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Form and Instruction	Removed
207646	2024 Active Bacterial Core Surveillance (ABCs) Case Report Form and Instruction	Modified
207646	2024 Active Bacterial Core Surveillance (ABCs) Case Report Form and Instruction	Modified

ICR Details