Information Collection

Human Infection with Novel Influenza A Virus Case Report Form

IC 199043 under ICR 202405-0920-001 · OMB 0920-0004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0004 can be found here:

Documents and Forms

Document Name Document Type
Human Infection with Novel Influenza A Virus Case Report Form Form
Human Infection with Novel Influenza A Virus Case Report Form Form
Human Infection with Novel Influenza A Virus Case Report Attachment K Human Infection with Novel Influenza A Virus Case Report Form.pdf Form
Human Infection with Novel Influenza A Virus Case Report Attachment K Human Infection with Novel Influenza A Virus Case Report Form.pdf Form
0920-0004 Human Infection with Novel Influenza A Virus Case Report Attachment K_Human Infection with Novel Influenza A Virus_CRF.docx Form and Instruction
0920-0004 Human Infection with Novel Influenza A Virus Case Report Attachment K_Human Infection with Novel Influenza A Virus_CRF.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Human Infection with Novel Influenza A Virus Case Report 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	NA	Human Infection with Novel Influenza A Virus Case Report Form (addition of Suspected Avian Source)	Attachment K Human Infection with Novel Influenza A Virus Case Report Form.pdf	NA	Yes	Yes	Fillable Printable
Form and Instruction	0920-0004	Human Infection with Novel Influenza A Virus Case Report Form 06MAY2024	Attachment K_Human Infection with Novel Influenza A Virus_CRF.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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	114	0	114
Annual IC Time Burden (Hours)	67	10	57
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.