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
DocumentType
Form 33 Attachment 17 Form15a QC ChecklistForm
Form 32 Attachment 16 Form 14a 10% Data Accuracy ReportForm
Form 31 Attachment 15 Form 13a Enrollment ReportForm
Form 30 Attachment 14 Form 12a Subject ChecklistForm
Form 29 Attachmnt 13 Form 11a Subject Withdrawal FormForm
Form 28 Attachment 12 Form 10a Chart Review -Inpatient HospitalizationForm
Form 27 Attachment 11 Form9a ED Chart ReviewForm
Form 26 Attachment 9 Form 7a Enrollment Speciment CollectionForm
Form 25 Attachment 2 Representative Informed Consent FormForm
Form 24 Attachment 10 Form 8a Follow Up AssessmentForm
Form 23 Attachment 8 Form 6a Medical HistoryForm
Form 22 Attachment 7 Form 5a Current SymptomsForm
Form 21 Attachment 6 Form 4a Demographic and Exposure InformationForm
Form 20 Attachment 5 Form 3a Subject IndentificationForm
Form 19 Attachment 4 Form 2a Eligibility ChecklistForm
Form 18 Attachment 2 Representative Informed Consent FormForm
Form 17 Attachment 2 Representative Informed Consent FormForm
Form 16 Attachment 10 Form 8a Follow Up AssessmentForm
Form 15 Attachment 8 Form 6a Medical HistoryForm
Form 14 Attachment 7 Form 5a Current SymptomsForm
Form 13 Attachment 6 Form 4a Demographic and Exposure InformationForm
Form 12 Attachment 5 Form 3a Subject IndentificationForm
Form 11 Attachment 4 Form 2a Eligibility ChecklistForm
Form 10 Attachment 3 Form 1a Screening and Enrollment LogForm
Form 9 Attachment 2 Representative Informed Consent FormForm and Instruction
Form 8 Attachment 10 Form 8a Follow Up AssessmentForm
Form 7 Attachment 8 Form 6a Medical HistoryForm
Form 6 Attachment 7 Form 5a Current SymptomsForm
Form 5 Attachment 6 Form 4a Demographic and Exposure InformationForm
Form 4 Attachment 5 Form 3a Subject IndentificationForm
Form 3 Attachment 4 Form 2a Eligibility ChecklistForm
Form 2 Attachment 3 Form 1a Screening and Enrollment LogForm
Form 1 Attachment 2 Representative Informed Consent FormForm and Instruction
Influenza Sub-Study Template Example 2 26 2016.doc Supplementary Document
USGHIS_Statement B_GENERIC_OMB_2-26-16.docxSupporting Statement B
NIAID 30-day notice.pdf Supplementary Document
USGHIS_Statement A_GENERIC_OMB2-FINAL.docxSupporting 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
ReferenceFilingReceivedConcludedAction
201509-0925-002 New collection (Request for a new OMB Control Number) 2015-09-30 Approved with change