MPEP for M. TB and non-tuberculous Mycobacteria Drug Susceptibility Testing Results Worksheet

Centers for Disease Control and Prevention Performance Evaluation Program for Mycobacterium Tuberculosis/Non-tuberculosis Mycobacteria Drug Susceptibility Testing Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0600 can be found here:

Documents and Forms

Document Name Document Type
MPEP for M. TB and non-tuberculous Mycobacteria Drug Susceptibility Testing Results Worksheet Form
Results Worksheet 0920-0600 Attachment 4c Gen Instruction and Results Worksheet (2).doc Form
Revised Results Worksheet NewFormTB Questions.1.doc Form
Results Worksheet - revised 5/2011 Result Booklet 2011_0504.docx Form
0920-0600 Attachment 4d NTM Case History Form.doc Case history example IC Document
0920-0600 Attachment 4a Pre-Shipment Letter.doc Pre-shipment letter IC Document
0920-0600 Attachment 4b Shipment and Password Letter.doc Shipment password letter IC Document
0920-0600 Attachment 4ei Reminder Email.doc Reminder email IC Document
0920-0600 Attachment 4eii Phone Script.doc Reminder telephone script IC Document
0920-0600 Attachment 4f Prelim Results Letter.doc Preliminary report IC Document
0920-0600 Attachment 4g Aggregate Results Letter.doc Aggregate report letter IC Document

Information Collection (IC) Details

IC Title:	MPEP for M. TB and non-tuberculous Mycobacteria Drug Susceptibility Testing Results Worksheet	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Results Worksheet	0920-0600 Attachment 4c Gen Instruction and Results Worksheet (2).doc	Yes	Yes	Fillable Fileable
Form	none	Revised Results Worksheet	NewFormTB Questions.1.doc	Yes	Yes	Fillable Fileable
Form	none	Results Worksheet - revised 5/2011	Result Booklet 2011_0504.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 132	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	264	264
Annual IC Time Burden (Hours)	132	132
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Case history example	0920-0600 Attachment 4d NTM Case History Form.doc	12/16/2009
Pre-shipment letter	0920-0600 Attachment 4a Pre-Shipment Letter.doc	12/16/2009
Shipment password letter	0920-0600 Attachment 4b Shipment and Password Letter.doc	12/16/2009
Reminder email	0920-0600 Attachment 4ei Reminder Email.doc	12/16/2009
Reminder telephone script	0920-0600 Attachment 4eii Phone Script.doc	12/16/2009
Preliminary report	0920-0600 Attachment 4f Prelim Results Letter.doc	12/16/2009
Aggregate report letter	0920-0600 Attachment 4g Aggregate Results Letter.doc	12/16/2009

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