Contact Investigation Outcome Reporting Forms

OMB 0920-0900

The purpose of this information collection is to obtain sufficient information on the results of contact investigations carried out by state and local public health professionals or maritime medical crews to assess the impact of a confirmed communicable disease of public health concern in a traveler. Information is used to assess the impact in terms of spread and health outcomes and to determine if further public health intervention is appropriate. Communicable diseases of interest include clinically active tuberculosis (TB), varicella, influenza-like illness, measles, and rubella. The purpose of this non-substantive Change Request (submitted August 2018) is to clarify the wording of selected questions on the ILI Outbreak Enhanced Data Collection Form.

The latest form for Contact Investigation Outcome Reporting Forms expires 2021-05-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Influenza-like Illness Investigation Outcome Reporting Form - Maritime Form and Instruction
Varicella Investigation Outcome Reporting Form Form
Form 0920-0900 State/Local Rubella Outcome Reporting (Air) Form
Form 0920-0900 State/Local Measles Outcome Reporting (Air) Form
Cruise Ship TB Outcome Reporting - Maritime (Word) Form
Form 0920-0900 State/Local TB Outcoming Reporting (Air) Form
Form 0920-0900 State/Local General Outcome Reporting (Air) Form
Form 0920-0900 State/Local General Contact Reporting (Land) Form
TB Contact Investigation Outcome Reporting Form_Air_rev10.2021.pdf Supplementary Document
0920-0900_Non-sub change request_10.04.21.docx Justification for No Material/Nonsubstantive Change
0920-0900 SupSta B 05182021.docx Supporting Statement B
0920-0900 SupSta A 05182021.docx Supporting Statement A
Attachment L - QARS PIA.pdf Supplementary Document
Attachment C - Non-research Determination.pdf Supplementary Document
Attachment B1- Public Comment-0920-0900-3.8.2021FRNPosting.docx Supplementary Document
Attachment B 2021-0920-0900-60dayFRN.pdf Supplementary Document
Attachment A3 42 CFR part 71.pdf Supplementary Document
Attachment A2 42 CFR part 70.pdf Supplementary Document
Attachment A1 Section 361 of the Public Health Service Act (42 USC 264).....pdf Supplementary Document
Influenza-like Illness Investigation Outcome Reporting Form - Maritime Form and Instruction
Varicella Investigation Outcome Reporting Form Form
State/Local Rubella Outcome Reporting (Air) Form
State/Local Measles Outcome Reporting (Air) Form
Cruise Ship TB Outcome Reporting - Maritime (Word) Form
State/Local TB Outcoming Reporting (Air) Form
State/Local General Outcome Reporting (Air) Form
State/Local General Contact Reporting (Land) Form

All Historical Document Collections

202111-0920-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2021-11-02
202105-0920-009 Approved without change	Revision of a currently approved collection	2021-05-28
201808-0920-021 Approved without change	No material or nonsubstantive change to a currently approved collection	2018-08-29
201802-0920-005 Approved without change	Revision of a currently approved collection	2018-04-20
201712-0920-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2017-12-14
201609-0920-017 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-09-29
201510-0920-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2015-10-21
201502-0920-008 Approved with change	Revision of a currently approved collection	2015-03-03
201407-0920-002 Approved with change	Revision of a currently approved collection	2014-07-17
201106-0920-017 Approved without change	New collection (Request for a new OMB Control Number)	2011-06-27
201106-0920-007 Improperly submitted	New collection (Request for a new OMB Control Number)	2011-06-10
201106-0920-002 Improperly submitted	New collection (Request for a new OMB Control Number)	2011-06-01

OMB Details

State/Local General Contact Reporting (Land)

Federal Enterprise Architecture: Health - Public Health Monitoring

Form n/a

General Contact Investigation Outcome Reporting Form (Land)

Fillable Fileable

Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.