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

Document Name
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

201509-0925-002

Approved with change

New collection (Request for a new OMB Control Number)

2015-09-30