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US/WHO International Clinical Network Ebola Virus Disease Clinical Data Collection Tool
Data Supplement for Ebola Virus Disease Patients Treated Outside of West Africa
OMB: 0920-1069
IC ID: 216874
OMB.report
HHS/CDC
OMB 0920-1069
ICR 201506-0920-002
IC 216874
( )
Documents and Forms
Document Name
Document Type
US/WHO International Clinical Network Ebola Virus Disease Clinical Data Collection Tool
Form
US/WHO Clinical Network EVD Data Collection Tool
AppndxC US-WHO ClinNetworkEVDDataCollTool 20150604.xlsx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
US/WHO International Clinical Network Ebola Virus Disease Clinical Data Collection Tool
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
None
US/WHO Clinical Network EVD Data Collection Tool
AppndxC US-WHO ClinNetworkEVDDataCollTool 20150604.xlsx
None
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Disaster Management
Subfunction:
Emergency Response
Privacy Act System of Records
Title:
Epidemic Investigation Case Records
FR Citation:
51 FR 42466
Number of Respondents:
21
Number of Respondents for Small Entity:
18
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
42
0
42
0
0
0
Annual IC Time Burden (Hours)
32
0
32
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.