FluSurv-Net Influenza Hospitalization Surveillance Network 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⚠️ Notice: This information collection may be referencing outdated material.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 FSN.300.1 FluSurv-Net Influenza Hospitalization Surveillance Network Case Report Form Form and Instruction
FSN.300.1 Influenza Hospitalizatin Surveillance Network (FluSurv-N FSN.300.1 FluSurv-NET CRF.pdf Form and Instruction
FSN.300.1 Influenza Hospitalizatin Surveillance Network (FluSurv-N FSN.300.1 FluSurv-NET CRF.pdf Form and Instruction
Att16_COVID-19 Vaccination Status on FluSurv-NET Cases.pdf COVID Vaccination Status on FluSurv-NET cases (optional) IC Document
Att16_COVID-19 Vaccination Status on FluSurv-NET Cases.pdf COVID Vaccination Status on FluSurv-NET cases (optional) IC Document

Information Collection (IC) Details

IC Title:	FluSurv-Net Influenza Hospitalization Surveillance Network Case Report Form	Agency IC Tracking Number:	0920-0978

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FSN.300.1	Influenza Hospitalizatin Surveillance Network (FluSurv-NET) Case Report Form	FSN.300.1 FluSurv-NET CRF.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	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	8,640	-2,265	10,905
Annual IC Time Burden (Hours)	3,600	-944	4,544
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
COVID Vaccination Status on FluSurv-NET cases (optional)	Att16_COVID-19 Vaccination Status on FluSurv-NET Cases.pdf	12/28/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.