Information Collection

Data Elements Transferred to CDC for the HAIC Death Ascertainment Project

IC 253051 under ICR 202509-0920-011 · OMB 0920-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HAIC.400.13 Data Elements Transferred to CDC for the HAIC Death Ascertainment Project	Form and Instruction
Form HAIC.400.13 Data Elements Transferred to CDC for the HAIC Death Ascertainment Project Data Elements Transferred to CDC for the HAIC Death Ascertainment Project	Form and Instruction
HAIC.400.13 Data Elements Transferred to CDC for the HAIC Death Asce HAIC.400.13 HAIC Death Ascertainment Project.pdf	Form and Instruction
HAIC.400.13 Data Elements Transferred to CDC for the HAIC Death Asce HAIC.400.13 HAIC Death Ascertainment Project.pdf	Form and Instruction

IC Title:

Data Elements Transferred to CDC for the HAIC Death Ascertainment Project

Agency IC Tracking Number:

0920-0978

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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	HAIC.400.13				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	1,920	1,920
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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