Information Collection

Candidemia Case Report Form

IC 231114 under ICR 202604-0920-003 · OMB 0920-0978.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HAIC.400.11 CANDIDEMIA CASE REPORT FORM CANDIDEMIA CASE REPORT FORM	Form and Instruction
HAIC.400.11 CANDIDEMIA CASE REPORT FORM HAIC.400.11 2025 Candidemia CRF Final.pdf	Form and Instruction

IC Title:

CANDIDEMIA CASE REPORT FORM

Agency IC Tracking Number:

0920-0978

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 PHSA

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.400.11			N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

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
	Requested	Previously Approved
Annual Number of Responses for this IC	1,700	1,700
Annual IC Time Burden (Hours)	1,133	1,133
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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