OMB control number

[NCEZID] Characteristics of Cases of Priority Fungal Diseases

OMB 0920-1385 · HHS/CDC.

OMB 0920-1385

For patients involving triazole-resistant A. fumigatus isolates detected through passive public health surveillance, we will use a standardized case report form to collect public health surveillance data regarding demographics, underlying medical conditions, treatments, and outcomes. Health departments would be asked to voluntarily fill out the de-identified form. Proposed changes for this Revision include the addition of five new CRFs and changes to a current form.

The latest form for [NCEZID] Characteristics of Cases of Priority Fungal Diseases expires 2028-02-29 and is listed under ICR 202501-0920-004.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form 0920-1385 Sporotrichosis case report form	Form
Form 0920-1385 Sporotrichosis case report form	Form
Form 0920-1385 Mycetoma case report form	Form
Form 0920-1385 Mycetoma case report form	Form
Form 0920-1385 Chromoblastomycosis case report form	Form
Form 0920-1385 Chromoblastomycosis case report form	Form
Form 0920-1385 Antifungal-resistant dermatophytosis case report form	Form
Form 0920-1385 Antifungal-resistant dermatophytosis case report form	Form
Form 0920-1385 Candida auris Case Report Form	Form
Form 0920-1385 Candida auris Case Report Form	Form
Form 0920-1385 Blastomycosis Case Report Form	Form
Form 0920-1385 Blastomycosis Case Report Form	Form
Form 0920-1385 Histoplasmosis Case Report Form	Form
Form 0920-1385 Histoplasmosis Case Report Form	Form
Form 0920-1385 Coccidioidomycosis Case Report Form	Form
Form 0920-1385 Coccidioidomycosis Case Report Form	Form
Form 0920-1385 Triazole-resistant Aspergillus fumigatus case reporting	Form
Form 0920-1385 Triazole-resistant Aspergillus fumigatus Case Report Form	Form
Att 1 Section 301 of the Public Health Service Act (42 USC 241).pdf	Supplementary Document
Att 1 Section 301 of the Public Health Service Act (42 USC 241).pdf	Supplementary Document
Att. 4 Non Research Determination.pdf	Supplementary Document
Att. 5- Privacy Impact Assessment.pdf	Supplementary Document
Att 4- Human Subjects Determination.pdf	Supplementary Document
Att 2-Published 60-day FRN.pdf	Supplementary Document
Att 1 Section 301 of the Public Health Service Act (42 USC 241).pdf	Supplementary Document
SSB FungiSurv1_Revision_FINAL.docx	Supporting Statement B
SSB FungiSurv1_Revision_FINAL.docx	Supporting Statement B
SSA FungiSurv1_Revision_FINAL.docx	Supporting Statement A
SSA FungiSurv1_Revision_FINAL.docx	Supporting Statement A
Sporotrichosis case report form	Form
Sporotrichosis case report form	Form
Mycetoma case report form	Form
Mycetoma case report form	Form
Chromoblastomycosis case report form	Form
Chromoblastomycosis case report form	Form
Antifungal-resistant dermatophytosis case report form	Form
Antifungal-resistant dermatophytosis case report form	Form
Candida auris Case Report Form	Form
Candida auris Case Report Form	Form
Blastomycosis Case Report Form	Form
Blastomycosis Case Report Form	Form
Histoplasmosis Case Report Form	Form
Histoplasmosis Case Report Form	Form
Coccidioidomycosis Case Report Form	Form
Coccidioidomycosis Case Report Form	Form
Triazole-resistant Aspergillus fumigatus Case Report Form	Form
Triazole-resistant Aspergillus fumigatus Case Report Form	Form

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202501-0920-004	Revision of a currently approved collection	2025-01-16
202402-0920-008	Revision of a currently approved collection	2024-03-14	Approved with change
202205-0920-013	New collection (Request for a new OMB Control Number)	2022-06-07	Approved without change

OMB Details

Triazole-resistant Aspergillus fumigatus Case Report Form

Federal Enterprise Architecture: Health - Public Health Monitoring

Information collection instruments
Form	Name	Electronic access	Type
Form 0920-1385	Triazole-resistant Aspergillus fumigatus case reporting	Fillable Fileable	Form

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