National Disease Surveillance Program

Forms and Documents

Document Name	Status
Form none assigned Tularemia Form	Modified
Form none assigned Trichinosis Surveillance Case Report Form	Modified
Form none assigned Tick-borne Rickettsial Disease Case Report Form	Modified
Form none assigned Reye Syndrome Case Surveillance Report Form	Modified
Form none assigned Q Fever Form	Modified
Form none assigned Plaque Case Investigation Report Form	Modified
Form CDC 54.1 Malaria Case Surveillance Report Form	Modified
Form none assigned Lyme Disease Report Form	Modified
Form CDC 52.56 Legionellosis Case Report Form	Modified
Form none assigned Kawasaki Syndrome Form	Modified
Form none assigned Hantavirus Pulmonary Syndrome Form	Modified
Form none assigned Dengue Case Investigation Form	Modified
Form none assigned Cyclosporiasis Form	Modified
Form none assigned CJD Form	Modified
Form No number Viral Hepatitis Case Record Form	Modified
Form No number Typhoid Fever Surveillance Report Form	Modified
Leptospirosis Case Report Form	Modified
non-substantive change request - OMB 0920-0009_10 22 2013 rev.docx Justification for No Material/Nonsubstantive Change	2013-11-04
CDCMalaria54 1_changesAppenA2009.xls Supplementary Document	2010-02-25
Currentmalaria_form.pdf Supplementary Document	2010-02-25
DCIF_English_Color_proposed_jun2009.ppt Supplementary Document	2009-06-08

IC Document Collections

IC ID	Document Title	Status
46212	Tularemia Form	Modified
46211	Trichinosis Surveillance Case Report Form	Modified
46210	Tick-borne Rickettsial Disease Case Report Form	Modified
46209	Reye Syndrome Case Surveillance Report Form	Modified
46208	Q Fever Form	Modified
46207	Plaque Case Investigation Report Form	Modified
46206	Malaria Case Surveillance Report Form	Modified
46205	Lyme Disease Report Form	Modified
46204	Legionellosis Case Report Form	Modified
46203	Kawasaki Syndrome Form	Modified
46202	Hantavirus Pulmonary Syndrome Form	Modified
46201	Dengue Case Investigation Form	Modified
46200	Cyclosporiasis Form	Modified
46199	CJD Form	Modified
46198	Viral Hepatitis Case Record Form	Modified
37710	Typhoid Fever Surveillance Report Form	Modified
207080	Leptospirosis Case Report Form	Modified

ICR Details

OMB Control No: 0920-0009	ICR Reference No: 201311-0920-001
Status: Historical Active	Previous ICR Reference No: 201305-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No: 20759
Title: National Disease Surveillance Program
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: 11/06/2013
	Date Received in OIRA: 11/05/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2016	04/30/2016	04/30/2016
Responses	45,259	0	45,259
Time Burden (Hours)	11,476	0	11,476
Cost Burden (Dollars)	0	0	0

---

Abstract: CDC requests streamlining the way the Legionellosis Case Report is received by having states that are interested extract data from their electronic system to send to CDC via secure FTP in a file format like Excel or Access. States will enter the information into their state electronic system, fill out a hard copy for CDC, then CDC will enter the inforamtion into the electronic system.

---

Authorizing Statute(s): US Code: 42 USC 301 Name of Law: General Powers and Duties of Public Health Service
   US Code: 42 USC 306 Name of Law: National Center for Health Statistics
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 17

IC Title	Form No.	Form Name
Typhoid Fever Surveillance Report	No number	Typhoid Fever Surveillance
Viral Hepatitis Case Record	No number	Hepatitis Case Record
CJD	none assigned	CJD
Cyclosporiasis	none assigned	Cyclosporiasis
Dengue Case Investigation	none assigned, none assigned	Dengue ,   Dengue-Spanish
Hantavirus Pulmonary Syndrome	none assigned	Hantavirus
Kawasaki Syndrome	none assigned	Kawasaki
Legionellosis Case Report	CDC 52.56	Legionellosis Case Report
Lyme Disease Report	none assigned	Lyme Disease
Malaria Case Surveillance Report	CDC 54.1	Malaria Case Surveillance Report
Plaque Case Investigation Report	none assigned	Plague
Q Fever	none assigned	Q Fever
Reye Syndrome Case Surveillance Report	none assigned	Reye Syndrome
Trichinosis Surveillance Case Report	none assigned	Trichinosis
Tularemia	none assigned	Tularemia
Tick-borne Rickettsial Disease Case Report	none assigned	Tick-Borne
Leptospirosis Case Report	none	Leptospirosis Case Report

---

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	45,259	45,259	0	0	0	0
Annual Time Burden (Hours)	11,476	11,476	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:

---

Annual Cost to Federal Government: $80,000

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

---

Common Form ICR:  No

---

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: 11/05/2013

---