Emerging Infections Program

Forms and Documents

Document Name	Status
Att16_Resistant Gram-Negative Bacilli Case Report Form Form	New
Att 15_CDI Telephone Interview Form	New
Att 14_CDI Screening Form Form	New
Att 11_CDI Treatment Form Form	New
Att 10_CDI Case Report Form Form	New
Form CDC 52.15A Att 3_2015 Active Bacterial Core Surveillance (ABCs) Case Report Non-Bacteremic Pneumoccoccal Disease Form	New
Att 8_FluSurv-Net Project Consent Form Form	Modified
Att 6_2014-15 Vaccination History Patient/Proxy Interview Form	Modified
Att 5_FluSurv-NET Influenza Hospitalization Surveilance Project Case Report Form Form	Modified
Legionellosis ABCs Case Report Form	Unchanged
ABCs Neonatal Infection Expanded Tracking Form Form	Unchanged
Att 2_ABCs Invasive Pneumococcal Disease in Children Form	Modified
Invasive Methicillin - Resistant - Staphylococcus aureus ABCs Case Report Form Form	Unchanged
Form CDC 52.15A Att 1_ABCs Case Report Form Form	Modified
2015 CRF Changes Summary.xlsx Supplementary Document	2015-01-16
EIP 2015 Change Request_justification_revised 1-12-15.docx Justification for No Material/Nonsubstantive Change	2015-01-16
Attachment 13 _ CDI ASSENT for 13-15.pdf Supplementary Document	2015-01-16
Attachment 12 _ADULT VERBAL CONSENT Assent 16_17 for CDI.PDF Supplementary Document	2015-01-16
Attachment 04_FoodNet Variable List_2014_12312013.pdf Supplementary Document	2015-01-16

IC Document Collections

IC ID	Document Title	Status
214679	Att16_Resistant Gram-Negative Bacilli Case Report Form Form	New
214678	Att 15_CDI Telephone Interview Form	New
214677	Att 14_CDI Screening Form Form	New
214676	Att 11_CDI Treatment Form Form	New
214675	Att 10_CDI Case Report Form Form	New
214674	Att 3_2015 Active Bacterial Core Surveillance (ABCs) Case Report Non-Bacteremic Pneumoccoccal Disease Form	New
207663	Yersinia Other-WORD	Unchanged
207662	Vibrio Other-WORD	Unchanged
207661	Shigella Other-WORD	Unchanged
207660	Shiga toxin producing E. coli Other-WORD	Unchanged
207659	Salmonella Other-WORD	Unchanged
207658	Listeria monocytogenes Other-WORD	Unchanged
207657	Cyclospora Other-WORD	Unchanged
207656	Cryptosporidium Other-WORD	Unchanged
207655	Campylobacter Other-WORD	Unchanged
207654	Att 8_FluSurv-Net Project Consent Form Form	Modified
207653	Att 6_2014-15 Vaccination History Patient/Proxy Interview Form	Modified
207652	Hemolytic Uremic Syndrome (HUS) Other-WORD	Unchanged
207651	Att 5_FluSurv-NET Influenza Hospitalization Surveilance Project Case Report Form Form	Modified
207650	Legionellosis ABCs Case Report Form	Unchanged
207649	ABCs Neonatal Infection Expanded Tracking Form Form	Unchanged
207648	Att 2_ABCs Invasive Pneumococcal Disease in Children Form	Modified
207647	Invasive Methicillin - Resistant - Staphylococcus aureus ABCs Case Report Form Form	Unchanged
207646	Att 1_ABCs Case Report Form Form	Modified

ICR Details

OMB Control No: 0920-0978	ICR Reference No: 201501-0920-018
Status: Historical Inactive	Previous ICR Reference No: 201402-0920-016
Agency/Subagency: HHS/CDC	Agency Tracking No: 15FZ
Title: Emerging Infections 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: Withdrawn and continue	Conclusion Date: 01/29/2015
	Date Received in OIRA: 01/22/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2016	08/31/2016	08/31/2016
Responses	41,200	0	41,200
Time Burden (Hours)	12,319	0	12,319
Cost Burden (Dollars)	0	0	0

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Abstract: CDC is requesting minor changes for 2015 reporting of diseases reported under the Emerging Infections Program.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

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

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 24

IC Title	Form No.	Form Name
Invasive Methicillin - Resistant - Staphylococcus aureus ABCs Case Report Form	none	Invasive Methicillin-Resistant Staph
Att 2_ABCs Invasive Pneumococcal Disease in Children	None	Active Bacterial Core Surveillance (ABCs) Invasive Pneumococcal Disease in Children
ABCs Neonatal Infection Expanded Tracking Form	none	Neonatal Tracking
Att 1_ABCs Case Report Form	CDC 52.15A	2015 Active Bacterial Core Surveillance (ABCs) Case Report
Legionellosis ABCs Case Report	none	Legionellosis Case Report
Att 5_FluSurv-NET Influenza Hospitalization Surveilance Project Case Report Form	none	FluSurv-NET Case Report
Salmonella
Shiga toxin producing E. coli
Shigella
Vibrio
Yersinia
Att 3_2015 Active Bacterial Core Surveillance (ABCs) Case Report Non-Bacteremic Pneumoccoccal Disease	CDC 52.15A	2015 Active Bacterial Core Surveillance (ABCs) Case Report Non-Bacteremic Pneumococcal Disease
Att 11_CDI Treatment Form	None	EIP CDI Surveillance: CDI Case Treatment Questionnaire
Att 15_CDI Telephone Interview	None	Community-associated Clostridium difficle Infection (CDI Surveillance Health Inter
Hemolytic Uremic Syndrome (HUS)
Att 6_2014-15 Vaccination History Patient/Proxy Interview	none	Att 6_2014-15 Vaccination History Patient/Proxy Interview (English)
Att 8_FluSurv-Net Project Consent Form	None	Verbal Consent Form
Campylobacter
Cryptosporidium
Cyclospora
Listeria monocytogenes
Att16_Resistant Gram-Negative Bacilli Case Report Form	None	2015 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report
Att 10_CDI Case Report Form	None	Clostridium Difficile Infection (CDI) Surveillance Emerging Infections Program Case Report
Att 14_CDI Screening Form	None	Screening Questions for Clostridium difficile Telephone Interview

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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: Yes

Burden Reduction Due to: Changing Forms

Short Statement: Requesting approval of a non-substantive change to modify forms and make minor burden changes. These forms are use to conduct surveillance to determine the incidence and epidemiologic characteristics of invasive diseases.

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Annual Cost to Federal Government: $6,872,123

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: 01/22/2015

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