Emergency Epidemic Investigation Data Collections - Expedited Reviews

Forms and Documents

Document Name	Status
Undetermined source for Salmonella Infantis infections among detention center inmates - South Carolina, 2016 Form and Instruction	New
Undetermined source, mode of transmission, and risk factors for Hepatitis A virus (HAV) transmission ‒ Hawaii, 2016 Form and Instruction	New
Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016 Form and Instruction	New
Undetermined Mode of Transmission_Zika Virus among Utah Community Members, 2016 Form and Instruction	New
Undetermined source of Elizabethkingia anophelis infections among Wisconsin residents - Wisconsin, 2016 Form and Instruction	New
Undetermined source and risk factors for botulism among prisoners at a correctional facility - Mississippi, 2016 Form and Instruction	New
Undetermined risk factors for Exophiala dermatitidis among oncology patients - New York City, 2016. Form and Instruction	New
Undetermined transmission and risk factors for multidrug-resistant Mycobacterium tuberculosis among Tribal members - Arizona, 2016 Form and Instruction	New
Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016 Form and Instruction	Unchanged
Undetermined risk factors for E.coli O157 among visitors to a goat dairy--Connecticut, 2016 Form and Instruction	Unchanged
Undetermined sources and risk factors for a Rift Valley Fever Outbreak-Uganda, 2016 Form and Instruction	Unchanged
Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016 Form and Instruction	Unchanged
Undetermined source of Elizabethkingia meningoseptica bloodstream infection among Wisconsin residents - Wisconsin, 2016 Form and Instruction	Unchanged
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Puerto Rico, 2016 Form and Instruction	Unchanged
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Brazil, 2016 Form and Instruction	Unchanged
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection – American Samoa, 2016 Form and Instruction	Unchanged
EEI Guillain-Barre Syndrome_Bahia Brazil Form	Unchanged
Undetermined risk factors for ocular syphilis - North Carolina, 2015 Form	Unchanged
Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015. Form and Instruction	Unchanged
Undetermined Source of an outbreak of Legionnaires' Disease among Hotel A Visitors - Hannibal, MO 2015 Form and Instruction	Unchanged
GAS_IL 2015 Form	Unchanged
Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015 Form and Instruction	Unchanged
Qualitative Investigation of HIV Transmission in Southeastern Indiana, 2015 Form and Instruction	Unchanged
PA NTM Form	Unchanged
Cholera_Kenya Form and Instruction	Unchanged
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 2. Data Collection Forms.pdf Supplementary Document	2016-04-27
Appendix 1. Burden Memos.pdf Supplementary Document	2016-04-27
0920-1011 Non-Substantive Change Request Memo_Y2Q4_4-1-2016.docx Justification for No Material/Nonsubstantive Change	2016-04-27
Appendix 2. Data Collection Forms.pdf Supplementary Document	2016-01-27
0920-1011 Non-Substantive Change Request Memo_Y2Q3_Subm 1-22-2016.docx Supplementary Document	2016-01-27
Appendix 1. Burden Memos.pdf Supplementary Document	2016-01-27
Appendix 2. Data Collection Forms_0920-1011.pdf Supplementary Document	2015-11-03
Appendix 1. Burden Memo_0920-1011.pdf Supplementary Document	2015-11-03
0920-1011 Non-Substantive Change Request Memo_Y2Q2_10-01-2015_Subm.docx Supplementary Document	2015-11-03
0920-1011 Non-Substantive Change Request Memo_Y2Q1_07-02-2015.docx Supplementary Document	2015-07-07
Appendix 2. Data Collection Forms.pdf Supplementary Document	2015-07-07
Appendix 1. Burden Memo.pdf Supplementary Document	2015-07-07
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
223019	Undetermined source for Salmonella Infantis infections among detention center inmates - South Carolina, 2016 Form and Instruction	New
222856	Undetermined source, mode of transmission, and risk factors for Hepatitis A virus (HAV) transmission ‒ Hawaii, 2016 Form and Instruction	New
222590	Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016 Form and Instruction	New
222574	Undetermined Mode of Transmission_Zika Virus among Utah Community Members, 2016 Form and Instruction	New
222478	Undetermined source of Elizabethkingia anophelis infections among Wisconsin residents - Wisconsin, 2016 Form and Instruction	New
221903	Undetermined source and risk factors for botulism among prisoners at a correctional facility - Mississippi, 2016 Form and Instruction	New
221731	Undetermined risk factors for Exophiala dermatitidis among oncology patients - New York City, 2016. Form and Instruction	New
221388	Undetermined transmission and risk factors for multidrug-resistant Mycobacterium tuberculosis among Tribal members - Arizona, 2016 Form and Instruction	New
220946	Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016 Form and Instruction	Unchanged
220781	Undetermined risk factors for E.coli O157 among visitors to a goat dairy--Connecticut, 2016 Form and Instruction	Unchanged
220762	Undetermined sources and risk factors for a Rift Valley Fever Outbreak-Uganda, 2016 Form and Instruction	Unchanged
220680	Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016 Form and Instruction	Unchanged
220097	Undetermined source of Elizabethkingia meningoseptica bloodstream infection among Wisconsin residents - Wisconsin, 2016 Form and Instruction	Unchanged
220062	Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Puerto Rico, 2016 Form and Instruction	Unchanged
220061	Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Brazil, 2016 Form and Instruction	Unchanged
220060	Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection – American Samoa, 2016 Form and Instruction	Unchanged
219577	EEI Guillain-Barre Syndrome_Bahia Brazil Form	Unchanged
219234	Undetermined risk factors for ocular syphilis - North Carolina, 2015 Form	Unchanged
219193	Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015. Form and Instruction	Unchanged
218903	Undetermined Source of an outbreak of Legionnaires' Disease among Hotel A Visitors - Hannibal, MO 2015 Form and Instruction	Unchanged
218858	GAS_IL 2015 Form	Unchanged
218802	Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015 Form and Instruction	Unchanged
217928	Qualitative Investigation of HIV Transmission in Southeastern Indiana, 2015 Form and Instruction	Unchanged
217651	PA NTM Form	Unchanged
217021	Cholera_Kenya Form and Instruction	Unchanged
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: 201604-0920-011
Status: Historical Active	Previous ICR Reference No: 201601-0920-017
Agency/Subagency: HHS/CDC	Agency Tracking No: 16AGF
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: 05/02/2016
	Date Received in OIRA: 04/28/2016
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: 49

IC Title	Form No.	Form Name
2014010-XXX Ebola_Guinea	0920-1011, 0920-1011	Appendix 1- Case Investigation Form ,   Appendix 2- Contact Tracing Form
20140006XXX Measles FSM
Pseudomonas NICU_CA
2014012-XXX Resp Illness UC_CA
Mucormycosis_Kansas	None, None	Infection Prevention and Control Questions for Investigation of Mucormycosis ,   Mucormycosis Data Abstraction Form
Undetermined risk factors for ocular syphilis - North Carolina, 2015	NA, NA	Abstraction Form ,   Interview Form
Undetermined source for Salmonella Infantis infections among detention center inmates - South Carolina, 2016	NA	Salmonella Infantis Infections among Detention Center Inmates - Case Interview Form
Tainted Beverage_Mozambique
Chikungunya_USVI	CDC 56.31 A REV. 06/2006	Dengue Case Investigation Report
2014011-XXX Ebola_Liberia	none, none	Case Report Form ,   Contact Listing Form
2014014-XXX Ebola_Sierra Leone
BSI_CA	none, none, none	Chart Abstraction ,   Outpatient Dialysis Practices Survey ,   Reprocessing Observation Checklist
Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015	NA, NA, NA, NA, NA, NA, NA, NA	Community Suyrvey - English ,   Community Survey - French ,   Medical Providers Interview Survey - English ,   Medical Providers Interview Survey - French ,   Rabies Official Interview Survey - English ,   Rabies Official Interview Survey - French ,   Public Health Official Interview Survey - English ,   Public Health Official Interview Survey - French
Undetermined sources and risk factors for a Rift Valley Fever Outbreak-Uganda, 2016	NA, NA	Risk Factor Questionnaire ,   Livestock Assessment Form
GAS_IL 2015	NA, NA	GAS_IL Medical Record Abstraction ,   GAS_IL Employee Questionnaire
Pediatric cluster of neurologic symptoms - Colorado	none, none	Medical Chart Abstraction ,   Family Interview Questionnaire
Ebola_West Africa_2014	none, none, none	Focus Group Guide ,   Observation Guide ,   Field Guide
Burkholderia Investigation_LA	None	Risk Assessment for Primate Research Center Employees and Inspectors
Cholera_Kenya	None, None	Community Questionnaire ,   Healthcare Worker Questionnaire
Qualitative Investigation of HIV Transmission in Southeastern Indiana, 2015	NA	HIV Risk Factors Interview Guide
PA NTM	none, none	Interview Questions ,   Records Abstraction Information
Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016	NA	Healthcare Professional Risk Assessment Questionnaire
Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015.	NA, NA, NA, NA	Community Assessment ,   Community Assessment - Spanish ,   Healthcare Worker Assessment ,   Healthcare Worker Assessment
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Puerto Rico, 2016	NA, NA	Zika Virus Disease Case Investigation Form ,   2016 Urgent Assessment of Blood Collection and Use in Puerto Rico in Response to the Zika Virus Outbreak
Undetermined risk factors for Exophiala dermatitidis among oncology patients - New York City, 2016.	NA, NA	CDC Call Script ,   NYC Healthcare Worker Questionnaire
Undetermined source of Elizabethkingia meningoseptica bloodstream infection among Wisconsin residents - Wisconsin, 2016	NA	Elizabethkingia Meningoseptica Case Investigation Form
Undetermined Source of an outbreak of Legionnaires' Disease among Hotel A Visitors - Hannibal, MO 2015	NA, NA	Legionella Environmental Assessment Form ,   Sample Data Sheet
2014005XXX_DiarrhealDisease_AS	none, none	Medical Abstraction Form ,   Case Questionnaire
2014015-XXX_Parechovirus_Multi	none, none	Chart Abstraction ,   Family interview
2014004XXX_Legionnaires' Disease_Alabama 2014	none, none	Record Abstraction ,   Interview Questionnaire
Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016	NA, NA, NA, NA	GBS_Columbia Case Control Investigation Questionnaire - English ,   GBS_Columbia Case Control Investigation Questionnaire - Spanish ,   GBS_Columbia Chart Abstraction Form - English ,   GBS_Columbia Chart Abstraction Form - Spanish
Undetermined transmission and risk factors for multidrug-resistant Mycobacterium tuberculosis among Tribal members - Arizona, 2016	NA, NA, NA	Case Abstraction Form ,   Case Interview Form ,   Contact Interview and Abstraction Form
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Brazil, 2016	NA, NA	Survey Questionnaire ,   Chart Abstraction
Undetermined source of Elizabethkingia anophelis infections among Wisconsin residents - Wisconsin, 2016	NA	Focus Group Discussion Guide
Undetermined source and risk factors for botulism among prisoners at a correctional facility - Mississippi, 2016	NA	Questionnaire for Prison Outreak of Clostridium Botulinum, June 2016
Undetermined Mode of Transmission_Zika Virus among Utah Community Members, 2016	NA	Community Member Questionnaire
Undetermined source, mode of transmission, and risk factors for Hepatitis A virus (HAV) transmission ‒ Hawaii, 2016	NA, NA	HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CASE QUESTIONNAIRE ,   HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CONTROL QUESTIONNAIRE
2014009-XXX_Chikungunya_US Service Org Volunteers
CCRF_Georgia	none, none, none	Case Investigation ,   KAP Survey ,   Consent
EEI Guillain-Barre Syndrome_Bahia Brazil	NA, NA, NA, NA	Case Control Questionnaire - GBS English ,   Case Control Questionnaire - GBS Portugese ,   Chart Abstraction Questionnaire - GBS English ,   Chart Abstraction Questionnaire - GBS Portugese
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection – American Samoa, 2016	NA	Zika Virus Disease Case Investigation Form
Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016	NA, NA, NA	Invasive GAS in LTCF 2016 - Employee Survey ,   Investigation of GAS outbreak in LTCF 2016 - Resident Record Extraction Form ,   Invasive GAS in Long Term Care Facility 2016 - Wound Care Survey
Undetermined risk factors for E.coli O157 among visitors to a goat dairy--Connecticut, 2016	NA	Festival A Interview Form
2014008-XXX Chikungunya_PR	none, none, none, none	Household Questionnaire ,   Individual Questionnaire ,   Case Report (English) ,   Case Report (Spanish)
2014016-XXX_Ebola_DRC
Ebola_TX	None, None	Appendix 1 - Ebola Case Investigation Form ,   Appendix 2 - Ebola Case Contact Questionnaire
2014E003XXX_MERS-CoV_GA	none, none	Questionnaire for Passengers and Crew ,   Follow-up Questionnaire for Asymptomatic Passengers and Crew
2014013-XXX_Resp Illness UAC_Multi
Dengue_AZ	CDC56.31A	DENGUE Case Investigation Report

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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: 04/28/2016

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