Information Collection

Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF)

IC 258095 under ICR 202603-0920-014 · OMB 0920-0004.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF) Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF)	Form and Instruction
Pediatric Hepatitis of Unknown Etiology Medical Record A Attachment GG, Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF).pdf	Form and Instruction

IC Title:

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:

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	n/a				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52

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	Previously Approved
Annual Number of Responses for this IC	104	104
Annual IC Time Burden (Hours)	78	78
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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