Emergency Epidemic Investigation Data Collections - Expedited Reviews

Forms and Documents

Document Name	Status
Monkeypox_ROC Form	New
Cholera_Kenya Form and Instruction	New
Burkholderia Investigation_LA Form and Instruction	Unchanged
Mucormycosis_Kansas Form and Instruction	Unchanged
CCRF_Georgia Form	Unchanged
Ebola_TX Form	Unchanged
Ebola_West Africa_2014 Form and Instruction	Unchanged
Pediatric cluster of neurologic symptoms - Colorado Form	Unchanged
BSI_CA Form	Unchanged
2014015-XXX_Parechovirus_Multi Form	Unchanged
2014011-XXX Ebola_Liberia Form	Unchanged
Form 0920-1011 2014010-XXX Ebola_Guinea Form and Instruction	Unchanged
2014008-XXX Chikungunya_PR Form	Unchanged
2014005XXX_DiarrhealDisease_AS Form	Unchanged
2014004XXX_Legionnaires' Disease_Alabama 2014 Form	Unchanged
2014E003XXX_MERS-CoV_GA Form	Unchanged
Appendix 1. Burden Memos.pdf Supplementary Document	2015-04-22
Appendix 2. Data Collection Forms.pdf Supplementary Document	2015-04-22
0920-1011 Non-Substantive Change Request Memo_Y1Q4_04-15-2015.docx Justification for No Material/Nonsubstantive Change	2015-04-22
0920-1011 Non-Substantive Change Request Memo_Y1Q3_03-02-2015.docx Justification for No Material/Nonsubstantive Change	2015-03-03
Appendix 1. Burden Memos.pdf Supplementary Document	2015-03-03
Appendix 2. Data Collection Forms.pdf Supplementary Document	2015-03-03
2014012-XXX_Burden Memo.docx Supplementary Document	2014-10-29
2014010-XXX_Burden Memo.docx Supplementary Document	2014-10-29
2014008-XXX Burden Memo.docx Supplementary Document	2014-10-29
2014007-XXX Burden Memo.docx Supplementary Document	2014-10-29
2014006-XXX Burden Memo.docx Supplementary Document	2014-10-29
2014005-XXX Burden Memo.docx Supplementary Document	2014-10-29
2014004-XXX Burden Memo.docx Supplementary Document	2014-10-29
2014003-XXX_Burden Memo.docx Supplementary Document	2014-10-29
Inventory.pdf Supplementary Document	2014-10-29
EEI GenICR 0920-1011_Attach E _Burden Memo_9_16_2014.docx Supplementary Document	2014-10-29
EEI GenICR 0920-0111_Attach D_Request for Approval 9-16-2014.docx Supplementary Document	2014-10-29
EEI GenICR 0920-1011_Attach C_ Steps Conduct Emer Epi Invest_10_20_14.docx Supplementary Document	2014-10-29
0920-1011 Non-Substantive Change Request Memo_revised.docx Justification for No Material/Nonsubstantive Change	2014-10-29
EEI GenICR_Sup St B_3_20_14.docx Supporting Statement B	2014-03-25
EEI GenICR 0920-13ZJ_App 6_Online Survey Case Finding Questionnaire_11-06-2013.docx Supplementary Document	2013-11-20
EEI GenICR 0920-13ZJ_App 5_Phone Interview Questionnaire Patient_11-06-2013_Subm.docx Supplementary Document	2013-11-20
EEI GenICR 0920-13ZJ_App 4_Q Fever Person Interview Questionnaire_11-14-2013_Subm.docx Supplementary Document	2013-11-20
EEI GenICR 0920-13ZJ_App 3 _Hantav Pulm Synd Questionnaire_11-14-2013_Subm.docx Supplementary Document	2013-11-20
EEI GenICR 0920-13ZJ_App 2_GBS Case Questionnaire_11-14-2013_Subm.docx Supplementary Document	2013-11-20
EEI GenICR 0920-13ZJ_App 1_Chart Abstract Form_11-14-2013_Subm.docx Supplementary Document	2013-11-20
EEI GenICR 0920-13ZJ_Attach H_Biospecimen Storage Consent_11-06-2013_Subm.docx Supplementary Document	2013-11-20
EEI GenICR_0920-13ZJ_Attach G _Emer Epi Invest_IRB Letter_11-06-2013_Subm.pdf Supplementary Document	2013-11-20
EEI Gen ICR 0920-13ZJ_Attach F_Epi Invest SORN_11-06-2013.doc Supplementary Document	2013-11-20
EEI GenICR 0920-13ZJ_Attach E _Burden Memo_3-20-14.docx Supplementary Document	2014-03-25
EEI_Attach D_Request for Approval_3_20_14.docx Supplementary Document	2014-03-25
EEI GenICR 0920-13ZJ_Attach C_ Steps Conduct Emer Epi Invest_3_20_14.docx Supplementary Document	2014-03-25
EEI GenICR_0920-13ZJ_Attach B _Emer Epi Invest_Pub 60-day FRN_11-06-2013_Subm.pdf Supplementary Document	2013-11-20
EEI GenICR_0920-13ZJ_Attach A_Auth Legis Emer Epi Invest_11-06-2013_Subm.pdf Supplementary Document	2013-11-20
EEI_GenICR_Sup St A_3_20_14.docx Supporting Statement A	2014-03-25

IC Document Collections

IC ID	Document Title	Status
217356	Monkeypox_ROC Form	New
217021	Cholera_Kenya Form and Instruction	New
214996	Burkholderia Investigation_LA Form and Instruction	Unchanged
214724	Tainted Beverage_Mozambique Other-WORD	Unchanged
214409	Mucormycosis_Kansas Form and Instruction	Unchanged
214244	Dengue_AZ Other-WORD	Unchanged
213373	CCRF_Georgia Form	Unchanged
213323	Ebola_TX Form	Unchanged
213274	Ebola_West Africa_2014 Form and Instruction	Unchanged
213233	Pseudomonas NICU_CA Other-WORD	Unchanged
213189	Pediatric cluster of neurologic symptoms - Colorado Form	Unchanged
213101	BSI_CA Form	Unchanged
212908	2014016-XXX_Ebola_DRC Other-WORD	Unchanged
212644	2014015-XXX_Parechovirus_Multi Form	Unchanged
212395	2014014-XXX Ebola_Sierra Leone Other-PDF	Unchanged
212348	2014013-XXX_Resp Illness UAC_Multi Other-WORD	Unchanged
212320	2014012-XXX Resp Illness UC_CA Other-WORD	Unchanged
212266	2014011-XXX Ebola_Liberia Form	Unchanged
212227	2014009-XXX_Chikungunya_US Service Org Volunteers	Unchanged
212127	2014010-XXX Ebola_Guinea Form and Instruction	Unchanged
211951	2014008-XXX Chikungunya_PR Form	Unchanged
211894	Chikungunya_USVI Other-WORD	Unchanged
211760	20140006XXX Measles FSM Other-WORD	Unchanged
211705	2014005XXX_DiarrhealDisease_AS Form	Unchanged
211702	2014004XXX_Legionnaires' Disease_Alabama 2014 Form	Unchanged
211682	2014E003XXX_MERS-CoV_GA Form	Unchanged

ICR Details

OMB Control No: 0920-1011	ICR Reference No: 201504-0920-005
Status: Historical Active	Previous ICR Reference No: 201502-0920-018
Agency/Subagency: HHS/CDC	Agency Tracking No: 15AEG
Title: Emergency Epidemic Investigation Data Collections - Expedited Reviews
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/12/2015
	Date Received in OIRA: 06/09/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2017	03/31/2017	03/31/2017
Responses	36,000	0	36,000
Time Burden (Hours)	18,000	0	18,000
Cost Burden (Dollars)	0	0	0

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Abstract: CDC submits the quarterly inventory of forms and burden memos per agreement with OMB.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: PHSA
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 41930	07/12/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 69854	11/21/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 26

IC Title	Form No.	Form Name
Tainted Beverage_Mozambique
CCRF_Georgia	none, none, none	Case Investigation ,   KAP Survey ,   Consent
2014016-XXX_Ebola_DRC
2014015-XXX_Parechovirus_Multi	none, none	Chart Abstraction ,   Family interview
20140006XXX Measles FSM
Burkholderia Investigation_LA	None	Risk Assessment for Primate Research Center Employees and Inspectors
2014010-XXX Ebola_Guinea	0920-1011, 0920-1011	Appendix 1- Case Investigation Form ,   Appendix 2- Contact Tracing Form
2014E003XXX_MERS-CoV_GA	none, none	Questionnaire for Passengers and Crew ,   Follow-up Questionnaire for Asymptomatic Passengers and Crew
Mucormycosis_Kansas	None, None	Infection Prevention and Control Questions for Investigation of Mucormycosis ,   Mucormycosis Data Abstraction Form
Chikungunya_USVI	CDC 56.31 A REV. 06/2006	Dengue Case Investigation Report
Ebola_West Africa_2014	none, none, none	Observation Guide ,   Field Guide ,   Focus Group Guide
Cholera_Kenya	None, None	Community Questionnaire ,   Healthcare Worker Questionnaire
BSI_CA	none, none, none	Chart Abstraction ,   Outpatient Dialysis Practices Survey ,   Reprocessing Observation Checklist
2014011-XXX Ebola_Liberia	none, none	Case Report Form ,   Contact Listing Form
2014009-XXX_Chikungunya_US Service Org Volunteers
2014008-XXX Chikungunya_PR	none, none, none, none	Household Questionnaire ,   Individual Questionnaire ,   Case Report (English) ,   Case Report (Spanish)
2014013-XXX_Resp Illness UAC_Multi
2014014-XXX Ebola_Sierra Leone
2014005XXX_DiarrhealDisease_AS	none, none	Medical Abstraction Form ,   Case Questionnaire
2014004XXX_Legionnaires' Disease_Alabama 2014	none, none	Record Abstraction ,   Interview Questionnaire
2014012-XXX Resp Illness UC_CA
Pediatric cluster of neurologic symptoms - Colorado	none, none	Medical Chart Abstraction ,   Family Interview Questionnaire
Pseudomonas NICU_CA
Ebola_TX	None, None	Appendix 1 - Ebola Case Investigation Form ,   Appendix 2 - Ebola Case Contact Questionnaire
Dengue_AZ	CDC56.31A	DENGUE Case Investigation Report
Monkeypox_ROC	none, none	Survey iin English ,   Survey in French

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	36,000	36,000	0	0	0	0
Annual Time Burden (Hours)	18,000	18,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new generic information collection request.

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Annual Cost to Federal Government: $1,510,099

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/09/2015

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