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

[NCEZID] Emerging Infections Program

⚠️ Notice: This information collection may be referencing outdated material.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 9/20/20 HAIC Multi-Site Gram-Negative Surveillance Initiative (MUGSI) Case Report Form Form
Form CS342262-A 9/20/20 HAIC Multi-Site Gram-Negative Surveillance Initiative (MUGSI) Case Report Form Form
CS342262-A 9/20/20 2024 Multi-site Gram-Negative Surveillance Initiative (M Att8_HAIC_2024_MuGSI_CRF_v2_Changes_Highlighted.pdf Form
CS342262-A 9/20/20 2024 Multi-site Gram-Negative Surveillance Initiative (M Att8_HAIC_2024_MuGSI_CRF_v2_Changes_Highlighted.pdf Form

Information Collection (IC) Details

IC Title:	HAIC Multi-Site Gram-Negative Surveillance Initiative (MUGSI) Case Report Form	Agency IC Tracking Number:	0920-0978-24BX

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 9/20/2023	2024 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare-Associated Infections Community Interface (HAIC) Case Report	Att8_HAIC_2024_MuGSI_CRF_v2_Changes_Highlighted.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 %

	Approved	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.