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Att D-4_Acute Flaccid Myelitis
National Disease Surveillance Program
OMB: 0920-0009
IC ID: 219461
OMB.report
HHS/CDC
OMB 0920-0009
ICR 202208-0920-011
IC 219461
( )
Documents and Forms
Document Name
Document Type
Form 0920-0009
Att D-4_Acute Flaccid Myelitis
Form and Instruction
0920-0009 Acute Flaccid Myelitis: Patient Summary Form
D4. patient-summary-form clean copy 5.3.2022.docx
Form and Instruction
0920-0009 Acute Flaccid Myelitis: Patient Summary Form
D4. patient-summary-form clean copy 5.3.2022.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Att D-4_Acute Flaccid Myelitis
Agency IC Tracking Number:
17AXX
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
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
0920-0009
Acute Flaccid Myelitis: Patient Summary Form
D4. patient-summary-form clean copy 5.3.2022.docx
NA
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
100
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
0 %
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
400
0
0
0
0
400
Annual IC Time Burden (Hours)
80
0
0
0
0
80
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.