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

Forms and Documents

Document Name	Status
Exposure Risk Assessment for Travelers from Ebola-Affected Countries Form	New
Air Travel Illness or Death Investigation Form	Unchanged
Land Travel Illness or Death Investigation Form	Unchanged
Form 0920-0821 International Maritime Illness or Death Investigation Form and Instruction	Unchanged
Non-substantive Change_Quarantine Station Illness Response Forms 0920-08....docx Justification for No Material/Nonsubstantive Change	2014-09-18
Non-substantive Change_Quarantine Station Illness Response Forms 0920-0821 09182014.docx Justification for No Material/Nonsubstantive Change	2014-09-18
Attachment B 71 21a Other illness reports MIDRS screenshot.pdf Supplementary Document	2013-03-29

IC Document Collections

IC ID	Document Title	Status
213021	Exposure Risk Assessment for Travelers from Ebola-Affected Countries Form	New
188000	Air Travel Illness or Death Investigation Form	Unchanged
187999	Land Travel Illness or Death Investigation Form	Unchanged
187997	International Maritime Illness or Death Investigation Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-0821	ICR Reference No: 201409-0920-006
Status: Historical Active	Previous ICR Reference No: 201304-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No: 19217
Title: Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing
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 with change	Conclusion Date: 09/18/2014
	Date Received in OIRA: 09/08/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	08/31/2015	08/31/2015
Responses	3,858	0	3,758
Time Burden (Hours)	319	0	314
Cost Burden (Dollars)	0	0	0

---

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, and other globally mobile persons. This request for change is to add the Exposure Risk Assessment for Travelers from Ebola Outbreak-Affected countries.

---

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

---

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

---

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

---

Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Air Travel Illness or Death Investigation	none	Air Travel Illness or Death Investigation
International Maritime Illness or Death Investigation	0920-0821	Attachment A Maritime investigation form
Land Travel Illness or Death Investigation	none	Land Travel Illness or Death Investigation
Exposure Risk Assessment for Travelers from Ebola-Affected Countries	none	Risk Assessment for Travelers from Ebola-Affected Countries

---

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	3,858	3,758	0	100	0	0
Annual Time Burden (Hours)	319	314	0	5	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This request for change is to add the Risk Assessment for Travelers from Ebola-Affected countries as discussed with OMB.

---

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

---

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: 09/08/2014

---