OMB control number
Long-term sequela of Rocky Mountain Spotted Fever (RMSF)
OMB 0920-1267 ยท HHS/CDC.
OMB 0920-1267
The goal of this study is to describe persistent neurological damage in patients who were hospitalized with RMSF. Resulting data will provide information to healthcare providers, patients, and policy-makers about the long term consequences of severe RMSF, including length of time to recovery, and risk factors during acute illness which may be associated with long-term impairment.
The latest form for Long-term sequela of Rocky Mountain Spotted Fever (RMSF) expires 2022-08-31 and is listed under ICR 201904-0920-004.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Neurologic Exam Form | Form |
| Patient Screening Questionnaire | Form |
 9. IRB Continuation Memo.docx | Supplementary Document |
| 8. RMSF-LTS PIA Signed.pdf | Supplementary Document |
| 7. Consent documents.pdf | Supplementary Document |
| 6. IRB Approval.docx | Supplementary Document |
| 5. Chart Abstraction Form.pdf | Supplementary Document |
| 2. 60-day FRN.pdf | Supplementary Document |
| 1. Section 301 of the Public Health Service Act (42 USC 241).pdf | Supplementary Document |
| Supporting Statement B_LTS_3-18-2019.docx | Supporting Statement B |
| Supporting Statement A_LTS_7-22-2019 CLEAN.docx | Supporting Statement A |
 Neurologic Exam Form |
Form |
| Patient Screening Questionnaire |
Form |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 201904-0920-004 | New collection (Request for a new OMB Control Number) | 2019-05-02 | Approved with change |
OMB Details
Patient Screening Questionnaire
Federal Enterprise Architecture: Health - Public Health Monitoring
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form none | Patient Screener | Paper Only | Form |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.