FluSurv-Net Influenza Hospitalization Surveillance Network Case Report Form (CFR)

[NCEZID] Emerging Infections Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:

Documents and Forms

Document Name Document Type
Form CS340190-A FluSurv-Net Influenza Hospitalization Surveillance Network Case Report Form (CFR) Form and Instruction
CS340190-A 2022-23 FluSurv-NET Influenza Hospitalization Surveillan Att6_FLU_FORM 2023-24 FluSurv-NET CRF_rev.07072023.pdf Form and Instruction
CS340190-A 2022-23 FluSurv-NET Influenza Hospitalization Surveillan Att6_FLU_FORM 2023-24 FluSurv-NET CRF_rev.07072023.pdf Form and Instruction
0920-0978 Data Collection Elements for COVID-19 Vaccination Status Att8_FLU_FORM COVID-19 Vaccination Status on 2324 FluSurv-NET cases_20230810.pdf Form
0920-0978 Data Collection Elements for COVID-19 Vaccination Status Att8_FLU_FORM COVID-19 Vaccination Status on 2324 FluSurv-NET cases_20230810.pdf Form

Information Collection (IC) Details

IC Title:	FluSurv-Net Influenza Hospitalization Surveillance Network Case Report Form (CFR)	Agency IC Tracking Number:	0920-0978-23HY

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CS340190-A	2022-23 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form	Att6_FLU_FORM 2023-24 FluSurv-NET CRF_rev.07072023.pdf		Yes	Yes	Fillable Fileable
Form	0920-0978	Data Collection Elements for COVID-19 Vaccination Status on 2023-24 FluSurv-NET Cases	Att8_FLU_FORM COVID-19 Vaccination Status on 2324 FluSurv-NET cases_20230810.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,905	1,135	9,770
Annual IC Time Burden (Hours)	4,544	1,361	3,183
Annual IC Cost Burden (Dollars)	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.