Novel Influenza A Virus Case Screening Form

[NCIRD] National Disease Surveillance Program - II. Disease Summaries

Documents and Forms

Document Name Document Type
Novel Influenza A Virus Case Screening Form Form
Novel Influenza A Virus Case Screening Form Form
Novel Influenza A Virus Case Screening Form Attachment P Novel Influenza A Virus Case Screening Form.pdf Form
Novel Influenza A Virus Case Screening Form Attachment P Novel Influenza A Virus Case Screening Form.pdf Form
0920-0004 Novel Influenza A Virus Case Screening Form 06MAY2024 Attachment P_Novel Influenza A Virus Case_Screening Form.docx Form and Instruction
0920-0004 Novel Influenza A Virus Case Screening Form 06MAY2024 Attachment P_Novel Influenza A Virus Case_Screening Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Novel Influenza A Virus Case Screening Form	Agency IC Tracking Number:

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	None	Novel Influenza A Virus Case Screening Form	Attachment P Novel Influenza A Virus Case Screening Form.pdf		Yes	Yes	Fillable Printable
Form and Instruction	0920-0004	Novel Influenza A Virus Case Screening Form 06MAY2024	Attachment P_Novel Influenza A Virus Case_Screening Form.docx	N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 57	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	57	57
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	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.