Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

Forms and Documents

Document Name	Status
Air Travel Illness or Death Investigation Form	Modified
Land Travel Illness or Death Investigation Form	Modified
International Maritime Illness or Death Investigation Form	Modified
0821 Illness Response Forms Renewal Part B 3_28_12.docx Supporting Statement B	2012-07-23
Land Form Change Justification.docx Supplementary Document	2012-07-23
Maritime Justification_3.docx Supplementary Document	2012-07-23
Air Form Change Justification.docx Supplementary Document	2012-07-23
Attachment F - Quarantine-Stations-Jurisdictions.pdf Supplementary Document	2012-07-23
Attachment C - Critieria for Ill Person Reporting- aviation.pdf Supplementary Document	2012-07-23
Attachment D Revised Ill Person Reporting.docx Supplementary Document	2012-07-23
Attachment B 42 CFR Part 70 and 71.pdf Supplementary Document	2012-07-23
Attachment J 0920-0821 60 day.pdf Supplementary Document	2012-07-23
Attachment E - 42 CFR Part 71.31Subpart D.pdf Supplementary Document	2012-07-23
Attachment A- Section 361 PHS Act.doc Supplementary Document	2012-07-23
0821 Illness Response Forms Renewal Part A 6_27_12.doc Supporting Statement A	2012-07-23

IC Document Collections

IC ID	Document Title	Status
188000	Air Travel Illness or Death Investigation Form	Modified
187999	Land Travel Illness or Death Investigation Form	Modified
187997	International Maritime Illness or Death Investigation Form	Modified

ICR Details

OMB Control No: 0920-0821	ICR Reference No: 201207-0920-012
Status: Historical Active	Previous ICR Reference No: 201012-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/31/2012
	Date Received in OIRA: 07/27/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved	09/30/2012
Responses	3,758	0	3,758
Time Burden (Hours)	377	0	439
Cost Burden (Dollars)	0	0	0

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Abstract: Quarantine station staff work in partnership with international, federal, state, and local agencies and organizations to fulfill their mission to reduce morbidity and mortality among immigrants, refugees, travelers, expatriates, adn other globally mobile persons.

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Authorizing Statute(s): US Code: 42 USC 361 Name of Law: Public Health Services Act
   US Code: 42 USC 71 Name of Law: Foreign Quarantine
  

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:
	77 FR 24210	04/23/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 40360	07/09/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
International Maritime Illness or Death Investigation	none	Maritime Conveyance Illness or Death Investigation
Land Travel Illness or Death Investigation	none	Land Travel Illness or Death Investigation
Air Travel Illness or Death Investigation	none	Air Travel Illness or Death Investigation

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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	3,758	3,758	0	0	0	0
Annual Time Burden (Hours)	377	439	0	-62	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This revision results in a decrease in burden due to changes in the content and format of the forms to improve efficiency and data usefulness through reorganization and improving the clarity of the questions.

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Annual Cost to Federal Government: $13,398

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: 07/27/2012

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