Influenza Associated Pediatric Mortality Case Report Form

[NCIRD] National Disease Surveillance Program - II. Disease Summaries

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0004 can be found here:

Documents and Forms

Document Name Document Type
Influenza Associated Pediatric Mortality Case Report Form Form
Influenza-Associated Pediatric Mortality Case Report Attachment J Influenza-Associated Pediatric Mortalit Case Report Form.pdf Form
Influenza-Associated Pediatric Mortality Case Report Attachment J Influenza-Associated Pediatric Mortalit Case Report Form.pdf Form

Information Collection (IC) Details

IC Title:	Influenza Associated Pediatric Mortality Case Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	NA	Influenza-Associated Pediatric Mortality Case Report	Attachment J Influenza-Associated Pediatric Mortalit Case Report Form.pdf	NA	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 57	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 65 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	114	114
Annual IC Time Burden (Hours)	57	57
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.