Candidemia Case Report Form

[NCEZID] Emerging Infections Program

Documents and Forms

Document Name Document Type
Form HAIC.400.11 CANDIDEMIA CASE REPORT FORM Form and Instruction
HAIC.400.11 CANDIDEMIA CASE REPORT FORM HAIC.400.11 2025 Candidemia CRF Final.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	CANDIDEMIA CASE REPORT FORM	Agency IC Tracking Number:	0920-0978

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 PHSA

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HAIC.400.11	CANDIDEMIA CASE REPORT FORM	HAIC.400.11 2025 Candidemia CRF Final.pdf	N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,700	1,700
Annual IC Time Burden (Hours)	1,133	1,133
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.