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Federal forms, ICRs, and supporting documents

Information Collection

[PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN)

IC 264737 under ICR 202410-0920-015 · OMB 0920-0879.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 0920-0879
[PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN)		 Form and Instruction
Form 0920-0879
[PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN)		 Form and Instruction
0920-0879 PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL RECORD A
Attachment A_Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form Controls_17Jan2024.docx 		Form and Instruction
0920-0879 PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL RECORD A
Attachment A_Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form Controls_17Jan2024.docx 		Form and Instruction
0920-0879 Pediatric Hepatitis of Unknown Etiology - Exposures Ques
Attachment B_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire [Parental Interview]_17Jan2024.docx 		Form and Instruction
0920-0879 Pediatric Hepatitis of Unknown Etiology - Exposures Ques
Attachment B_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire [Parental Interview]_17Jan2024.docx 		Form and Instruction
0920-0879 Pediatric Hepatitis of Unknown Etiology - Exposures Ques
Attachment C_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire CONTROL [Parental Interview]_17Jan2024.docx 		Form and Instruction
0920-0879 Pediatric Hepatitis of Unknown Etiology - Exposures Ques
Attachment C_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire CONTROL [Parental Interview]_17Jan2024.docx 		Form and Instruction
0920-0879 Hepatitis pediátrica de etiología desconocida - Cuestion
Att D_Hepatitis pediátrica de etiología desconocida - Cuestionario sobre exposiciones (entrevista a los padres). 8Dec2023.docx 		Form and Instruction
0920-0879 Hepatitis pediátrica de etiología desconocida - Cuestion
Att D_Hepatitis pediátrica de etiología desconocida - Cuestionario sobre exposiciones (entrevista a los padres). 8Dec2023.docx 		Form and Instruction
0920-0879 Hepatitis pediátrica de etiología desconocida. CONTROL d
Att E_Hepatitis pediátrica de etiología desconocida CONTROL del uestionario sobre exposiciones_8Dec2023.docx 		Form and Instruction
0920-0879 Hepatitis pediátrica de etiología desconocida. CONTROL d
Att E_Hepatitis pediátrica de etiología desconocida CONTROL del uestionario sobre exposiciones_8Dec2023.docx 		Form and Instruction
CSTLTS Generic Supporting_Statement_A_Guideline File_17Jan2024.docx
SSA		IC Document
CSTLTS Generic Supporting_Statement_A_Guideline File_17Jan2024.docx
SSA		IC Document
CSTLTS Generic Supporting_Statement_B_Guideline File_17Jan2024.docx
SSB		IC Document
CSTLTS Generic Supporting_Statement_B_Guideline File_17Jan2024.docx
SSB		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0920-0879 PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL RECORD ABSTRACTION FORM Attachment A_Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form Controls_17Jan2024.docx Yes Yes Fillable Fileable
Form and Instruction 0920-0879 Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire (Parental Interview) Attachment B_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire [Parental Interview]_17Jan2024.docx Yes Yes Fillable Fileable
Form and Instruction 0920-0879 Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire CONTROL (Parental Interview) Attachment C_Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire CONTROL [Parental Interview]_17Jan2024.docx Yes Yes Fillable Fileable
Form and Instruction 0920-0879 Hepatitis pediátrica de etiología desconocida - Cuestionario sobre exposiciones (entrevista a los padres) Att D_Hepatitis pediátrica de etiología desconocida - Cuestionario sobre exposiciones (entrevista a los padres). 8Dec2023.docx Yes Yes Fillable Fileable
Form and Instruction 0920-0879 Hepatitis pediátrica de etiología desconocida. CONTROL del cuestionario sobre exposiciones (Entrevista a los padres) Att E_Hepatitis pediátrica de etiología desconocida CONTROL del uestionario sobre exposiciones_8Dec2023.docx Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5,000 0 0 0 0 5,000
Annual IC Time Burden (Hours) 375 0 0 0 0 375
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
SSA CSTLTS Generic Supporting_Statement_A_Guideline File_17Jan2024.docx 01/26/2024
SSB CSTLTS Generic Supporting_Statement_B_Guideline File_17Jan2024.docx 01/26/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.