OMB control number

United States and Global Human Influenza Surveillance in at-Risk Settings (NIAID)

OMB 0925-0737 · HHS/NIH.

OMB 0925-0737

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form 33 Study Staff Form 15a QC Checklist	Form
Form 32 Study Staff Form 14a 10% Data accuracy report	Form
Form 31 Study Staff Form 13a Enrollment Report	Form
Form 30 Study Staff Form 12a Subject Checklist	Form
Form 29 Study Staff Form 11a Subject Withdrawl Form	Form
Form 28 Study Staff Form 10a Chart Review Inpatient Hospitalization	Form
Form 27 Study Staff Form 9a ED Chart Review	Form
Form 26 Study Staff Form 7a Enrollment Specimen Collection	Form
Form 25 Study Staff Informed Consent Form	Form
Form 24 Household Surveillance patients Form 8a Follow Up Assessment	Form
Form 23 Household Surveillance patients Form 6a Medical History	Form
Form 22 Household Surveillance patients Form 5a Current Symptoms	Form
Form 21 Household Surveillance patients Form 4a Demographic and Exposure Information	Form
Form 20 Household Surveillance patients Form 3a Subject Indentification	Form
Form 19 Household Surveillance patients Form 2a Eligibility Checklist	Form
Form 18 Household Surveillance patients Form 1a Screening and enrollment log	Form
Form 17 Household Surveillance patients Informed Consent Form	Form
Form 16 Human Animal-interface patients, Form 8a Follow Up Assessment	Form
Form 15 Human Animal-interface patients, 6a Medical History	Form
Form 14 Human Animal-interface patients, Form 5a Current Symptoms	Form
Form 13 Human Animal-interface patients, Form 4a Demographic and Exposure Information	Form
Form 12 Human Animal-interface patients, Form 3a Subject Identification	Form
Form 11 Human Animal interface patients Form 2a Eligibility Checklist	Form
Form 10 Human Animal interface patients Form 1a Screening and enrollment log	Form
Form 9 Human Animal interface patients Informed Consent Form	Form and Instruction
Form 8 Hospital/care setting patients, Form 8a Follow Up Assessment	Form
Form 7 Hospital/care setting patients, Form 6a Medical History	Form
Form 6 Hospital/care setting patients, Form 5a Current Symptoms	Form
Form 5 Hospital/care setting patients, Form 4a Demographic and Exposure Information	Form
Form 4 Hospital/care setting patients, Form 3a Subject Identification	Form
Form 3 Hospital/care setting patients, Form 2a Eligibility Checklist	Form
Form 2 Hospital/care setting patients, Form 1a Screening and enrollment log	Form
Form 1 Hospital/care setting patients, Informed Consent	Form and Instruction
Influenza Sub-Study Template Example 2 26 2016.doc	Supplementary Document
USGHIS_Statement B_GENERIC_OMB_2-26-16.docx	Supporting Statement B
NIAID 30-day notice.pdf	Supplementary Document
USGHIS_Statement A_GENERIC_OMB2-FINAL.docx	Supporting Statement A
Study Staff Form 15a QC Checklist	Form
Study Staff Form 14a 10% Data accuracy report	Form
Study Staff Form 13a Enrollment Report	Form
Study Staff Form 12a Subject Checklist	Form
Study Staff Form 11a Subject Withdrawl Form	Form
Study Staff Form 10a Chart Review Inpatient Hospitalization	Form
Study Staff Form 9a ED Chart Review	Form
Study Staff Form 7a Enrollment Specimen Collection	Form
Study Staff Informed Consent Form	Form
Household Surveillance patients Form 8a Follow Up Assessment	Form
Household Surveillance patients Form 6a Medical History	Form
Household Surveillance patients Form 5a Current Symptoms	Form
Household Surveillance patients Form 4a Demographic and Exposure Information	Form
Household Surveillance patients Form 3a Subject Indentification	Form
Household Surveillance patients Form 2a Eligibility Checklist	Form
Household Surveillance patients Form 1a Screening and enrollment log	Form
Household Surveillance patients Informed Consent Form	Form
Human Animal-interface patients, Form 8a Follow Up Assessment	Form
Human Animal-interface patients, 6a Medical History	Form
Human Animal-interface patients, Form 5a Current Symptoms	Form
Human Animal-interface patients, Form 4a Demographic and Exposure Information	Form
Human Animal-interface patients, Form 3a Subject Identification	Form
Human Animal interface patients Form 2a Eligibility Checklist	Form
Human Animal interface patients Form 1a Screening and enrollment log	Form
Human Animal interface patients Informed Consent Form	Form and Instruction
Hospital/care setting patients, Form 8a Follow Up Assessment	Form
Hospital/care setting patients, Form 6a Medical History	Form
Hospital/care setting patients, Form 5a Current Symptoms	Form
Hospital/care setting patients, Form 4a Demographic and Exposure Information	Form
Hospital/care setting patients, Form 3a Subject Identification	Form
Hospital/care setting patients, Form 2a Eligibility Checklist	Form
Hospital/care setting patients, Form 1a Screening and enrollment log	Form
Hospital/care setting patients, Informed Consent	Form and Instruction

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Concluded	Action
201509-0925-002	New collection (Request for a new OMB Control Number)	2015-09-30		Approved with change