Antiviral Resistant Influenza Infection Case Report Form

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

Documents and Forms

Document Name Document Type
Antiviral Resistant Influenza Infection Case Report Form Form
Antiviral Resistant Influenza Infection Case Report Form Form
Antiviral-Resistant Influenza Infection Case Report Attachment T Antiviral Resistant Influenza Infection Case Report Form.pdf Form
Antiviral-Resistant Influenza Infection Case Report Attachment T Antiviral Resistant Influenza Infection Case Report Form.pdf Form

Information Collection (IC) Details

IC Title:	Antiviral Resistant Influenza Infection Case Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	Antiviral-Resistant Influenza Infection Case Report	Attachment T Antiviral Resistant Influenza Infection Case 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: 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	171	171
Annual IC Time Burden (Hours)	86	86
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.