Information Collection

Late Onset Sepsis / Meningitis Event Form: Data Table for Monthly Electronic Upload

IC 238093 under ICR 202603-0920-006 · OMB 0920-0666.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.602 LOS / MEF: Data Table for Monthly Electronic Upload Late Onset Sepsis / Meningitis Event Form: Data Table for Monthly Electronic Upload	Form and Instruction
57.602 LOS / MEF: Data Table for Monthly Electronic Upload 57.602 LOSMEN Clean Version.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-0666

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	57.602				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,800	0	1,800
Annual IC Time Burden (Hours)	150	-30	180
Annual IC Cost Burden (Dollars)	0	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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