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Suspect Respiratory Virus Patient Form
[NCIRD] National Disease Surveillance Program - II. Disease Summaries
OMB: 0920-0004
IC ID: 228082
OMB.report
HHS/CDC
OMB 0920-0004
ICR 202405-0920-001
IC 228082
( )
Documents and Forms
Document Name
Document Type
Suspect Respiratory Virus Patient Form
Form
Suspect Respiratory Virus Patient Form
Form
Suspect Respiratory Virus Patient Form
Attachment CC Suspect Respiratory Virus Patient Form.pdf
Form
Suspect Respiratory Virus Patient Form
Attachment CC Suspect Respiratory Virus Patient Form.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Suspect Respiratory Virus Patient Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
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
Suspect Respiratory Virus Patient Form
Attachment CC Suspect Respiratory Virus Patient Form.pdf
NA
Yes
Yes
Fillable Printable
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:
10
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 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
50
0
0
0
0
50
Annual IC Time Burden (Hours)
25
0
0
0
0
25
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.