Information Collection

Influenza Associated Pediatric Mortality Case Report Form

IC 199050 under ICR 202603-0920-014 · OMB 0920-0004.

Documents and Forms

Document Name Document Type
Influenza-Associated Pediatric Mortality Case Report Influenza Associated Pediatric Mortality Case Report Form Form and Instruction
Influenza-Associated Pediatric Mortality Case Report Attachment J, Influenza-Associated Pediatric Mortality Case Report Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Influenza Associated Pediatric Mortality Case Report Form	Agency IC Tracking Number:	0920-26-0150

Is this a Common Form? No		IC Status: Modified

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 and Instruction	n/a	Influenza-Associated Pediatric Mortality Case Report	Attachment J, Influenza-Associated Pediatric Mortality Case Report Form.pdf	NA	Yes	Yes	Fillable Printable

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: 65 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	171	57	114
Annual IC Time Burden (Hours)	86	29	57
Annual IC Cost Burden (Dollars)	0	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.

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