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SEVERE NEUROLOGIC ILLNESS Chart Abstraction Questionnaire
Zika Virus Associated Neurologic Illness Case Control Study in Puerto Rico
OMB: 0920-1141
IC ID: 223950
OMB.report
HHS/CDC
OMB 0920-1141
ICR 201610-0920-005
IC 223950
( )
Documents and Forms
Document Name
Document Type
SEVERE NEUROLOGIC ILLNESS Chart Abstraction Questionnaire
Form and Instruction
Chart Abstraction Questionnaire for the Investigation of
CaCo Chart Abstraction Questionnaire_Severe Neuro_4Oct.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
SEVERE NEUROLOGIC ILLNESS Chart Abstraction Questionnaire
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
NA
Chart Abstraction Questionnaire for the Investigation of Severe Neurologic Illness in relation to Arboviral Infections
CaCo Chart Abstraction Questionnaire_Severe Neuro_4Oct.docx
NA
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
09-20-0136 - Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 62812
Number of Respondents:
10
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
60
0
60
0
0
0
Annual IC Time Burden (Hours)
60
0
60
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.