Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF)

[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⚠️ Notice: This information collection may be referencing outdated material.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
Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF) Form and Instruction
Pediatric Hepatitis of Unknown Etiology Medical Record A Att GG Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF).pdf Form and Instruction
Pediatric Hepatitis of Unknown Etiology Medical Record A Att GG Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF)	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	n/a	Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF)	Att GG Pediatric Hepatitis of Unknown Etiology Medical Record Abstraction Form (CRF).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	104	104
Annual IC Time Burden (Hours)	78	78
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.