Screening Form

Clostridium difficile Infection (CDI) Surveillance

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0892 can be found here:

Documents and Forms

Document Name Document Type
Form New form Screening Form Form and Instruction
New form Attachment E Screening Questions for CDI Attachment E - Screening Questions for Clostridium difficile Telephone Interview.doc Form and Instruction
Attachment D _ CDI ASSENT for 13-15 .doc Attachment D CDI Assent IC Document
Attachment C _ADULT VERBAL CONSENTrevised.doc Attachment C Adult Verbal Consent IC Document

Information Collection (IC) Details

IC Title:	Screening Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	New form	Attachment E Screening Questions for CDI	Attachment E - Screening Questions for Clostridium difficile Telephone Interview.doc		No	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment D CDI Assent	Attachment D _ CDI ASSENT for 13-15 .doc	06/16/2011
Attachment C Adult Verbal Consent	Attachment C _ADULT VERBAL CONSENTrevised.doc	06/16/2011

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