EVD Tracking Form for Healthcare Workers with Direct Patient Contact

Ebola Virus Disease in the United States:CDC Support for Case and Contact Investigation

Documents and Forms

Document Name Document Type
EVD Tracking Form for Healthcare Workers with Direct Patient Contact Form and Instruction
Contact Tracing Form for Health Care Workers caring for Att5a EVD Tracking Form for HCWs.xlsx Form and Instruction

Information Collection (IC) Details

IC Title:	EVD Tracking Form for Healthcare Workers with Direct Patient Contact	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	None	Contact Tracing Form for Health Care Workers caring for Ebola patients	Att5a EVD Tracking Form for HCWs.xlsx	None	Yes	Yes	Fillable Fileable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records
Title: 09-20-0113 Epidemic Investigation Case Record Systems Notice	FR Citation: 51 FR 42466

Number of Respondents: 300	Number of Respondents for Small Entity: 300

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 20 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,500	4,500
Annual IC Time Burden (Hours)	750	750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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