[NCEZID] Emerging Infections Program

ICR 202504-0920-028

OMB: 0920-0978

Federal Form Document

Forms and Documents

Document Name	Status
Form HAIC.400.13 Data Elements Transferred to CDC for the HAIC Death Ascertainment Project Form and Instruction	Unchanged
Form HAIC.400.3 2024 HAIC Multi-site Gram-negative Surveillance Initiative (MuGSI) Supplemental Surveillance Officer Survey Form and Instruction	Unchanged
Form HAIC.400.2 Community-Associated CP-CRE Interview Form and Instruction	Unchanged
Form HAIC.400.12 HAIC_LABORATORY TESTING PRACTICES FOR CANDIDEMIA QUESTIONNAIRE Form and Instruction	Unchanged
Form HAIC.400.6 2023 HAIC Invasive Staphylococcus aureus Supplemental Surveillance Officer Survey Form and Instruction	Unchanged
Form HAIC.400.5 CDC's Healthcare-Associated Infections Community Interface (HAIC) Staphylococcus aureus 2024 Laboratory Survey Form and Instruction	Unchanged
Form HAIC.400.10 Emerging Infections Program C. difficile Surveillance Nursing Home Telephone Survey Form and Instruction	Unchanged
Form HAIC.400.9 HAIC-Surveillance Officer's Survey Form and Instruction	Unchanged
Form HAIC.400.8 Annual Survey of Laboratory Testing Practices for C. difficile Infection Form and Instruction	Unchanged
Form FSN.300.4 FluSurv-NET Laboratory Survey 2023–2024 Season Form	Unchanged
Form FN.200.10 FoodNET Lab Survey Variable List 2024 Form	Unchanged
Form HAIC 400.11 CANDIDEMIA 2024 CASE REPORT FORM Form and Instruction	Modified
Form HAIC 400.4 Invasive Staphylococcus aureus Healthcare-Associated Infections Community Interface (HAIC) Case Report Form and Instruction	Modified
Form FSN.300.3 FLUSURV-NET: PROVIDER PEDIATRIC VACCINATION HISTORY REQUEST LETTER/FORM Form and Instruction	Unchanged
Form ABC.100.4 ABCs Severe GAS Infection: Supplemental Form Form and Instruction	Unchanged
Form ABC.100.3 2019 ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form Form and Instruction	Unchanged
Form HAIC 400.1 2024 (MuGSI) Healthcare-Associated Infections Community Interface (HAIC) Case Report Form and Instruction	Modified
Form HAIC 400.7 CLOSTRIDIOIDES DIFFICILE INFECTION (CDI) SURVEILLANCE EMERGING INFECTIONS PROGRAM CASE REPORT Form and Instruction	Modified
Form FN.200.8 FoodNet Variable List, 2024_ (YERSINIA) Form and Instruction	Unchanged
Form FN.200.7 FoodNet Variable List, 2024_ (VIBRIO) Form and Instruction	Unchanged
Form FN.200.6 FoodNet Variable List, 2024_ (SHIGELLA) Form and Instruction	Unchanged
Form FN.200.5 FoodNet Variable List, 2024_ (SHIGA TOXIN PRODUCING E.COLI) Form and Instruction	Unchanged
Form FN.200.4 FoodNet Variable List, 2024_ (SALMONELLA) Form and Instruction	Unchanged
Form FN.200.3 FoodNet Variable List, 2024_ (LISTERIA MONOCTOGENES) Form and Instruction	Unchanged
Form FN.200.2 FoodNet Variable List, 2024_ (CYCLOSPORA) Form and Instruction	Unchanged
Form FN.200.1 FoodNet Variable List, 2024_(CAMPYLOBACTER) Form and Instruction	Unchanged
Form FSN.300.2 FLUSURV-NET: CONSENT FORM FOR PATIENT/PROXY INTERVIEW (English/Spanish) Form and Instruction	Unchanged
Form ABC 200.9 FoodNet Hemolytic Uremic Syndrome (HUS) Form and Instruction	Modified
Form FSN.300.1 FluSurv-Net Influenza Hospitalization Surveillance Network Case Report Form Form and Instruction	Unchanged
Form ABC.100.5 Active Bacterial Core Surveillance (ABCs) Neonatal Infection Expanded Tracking Form Form and Instruction	Unchanged
Form ABC.100.2 ABCs Invasive Pneumococcal Disease in Children and Adults Form and Instruction	Unchanged
Form ABC.100.1 2024 Active Bacterial Core Surveillance (ABCs) Case Report Form and Instruction	Unchanged
EIP Change Request Memo - EO14168.docx Justification for No Material/Nonsubstantive Change	2025-04-28
Supporting Statement B_EIP OMB_updated_Clean.docx Supporting Statement B	2025-04-28
Supporting Statement A_EIP OMB_updated_clean.docx Supporting Statement A	2025-04-28
EIP 0920-0978_Non-sub change request_2025 08OCT2024.docx Justification for No Material/Nonsubstantive Change	2024-10-08
Att 2_Collection Instrument Cross walk.docx Supplementary Document	2024-10-08
Att 1 Program ChangesAdjustments_rev 08OCT2024.docx Supplementary Document	2024-10-08
Att. 6-Explanation for Program Changes.docx Supplementary Document	2024-07-11
Att. 5-Human Subjects Determination Memo.pdf Supplementary Document	2024-07-11
Att. 4a-Privacy Impact Assessment.pdf Supplementary Document	2024-07-11
Att. 2-Federal Register 60day FRN.pdf Supplementary Document	2024-07-11
Att. 1-Section 301 of the Public Health Service Act (42 USC 241).pdf Supplementary Document	2024-07-11

IC Document Collections

IC ID	Document Title	Status
253051	Data Elements Transferred to CDC for the HAIC Death Ascertainment Project Form and Instruction	Unchanged
253049	2024 HAIC Multi-site Gram-negative Surveillance Initiative (MuGSI) Supplemental Surveillance Officer Survey Form and Instruction	Unchanged
253048	Community-Associated CP-CRE Interview Form and Instruction	Unchanged
235058	HAIC_LABORATORY TESTING PRACTICES FOR CANDIDEMIA QUESTIONNAIRE Form and Instruction	Unchanged
235057	2023 HAIC Invasive Staphylococcus aureus Supplemental Surveillance Officer Survey Form and Instruction	Unchanged
235056	CDC's Healthcare-Associated Infections Community Interface (HAIC) Staphylococcus aureus 2024 Laboratory Survey Form and Instruction	Unchanged
235055	Emerging Infections Program C. difficile Surveillance Nursing Home Telephone Survey Form and Instruction	Unchanged
235054	HAIC-Surveillance Officer's Survey Form and Instruction	Unchanged
235053	Annual Survey of Laboratory Testing Practices for C. difficile Infection Form and Instruction	Unchanged
235052	FluSurv-NET Laboratory Survey 2023–2024 Season Form	Unchanged
235051	FoodNET Lab Survey Variable List 2024 Form	Unchanged
231114	CANDIDEMIA 2024 CASE REPORT FORM Form and Instruction	Modified
231113	Invasive Staphylococcus aureus Healthcare-Associated Infections Community Interface (HAIC) Case Report Form and Instruction	Modified
231111	FLUSURV-NET: PROVIDER PEDIATRIC VACCINATION HISTORY REQUEST LETTER/FORM Form and Instruction	Unchanged
230869	ABCs Severe GAS Infection: Supplemental Form Form and Instruction	Unchanged
220380	2019 ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form Form and Instruction	Unchanged
217336	2024 (MuGSI) Healthcare-Associated Infections Community Interface (HAIC) Case Report Form and Instruction	Modified
217334	CLOSTRIDIOIDES DIFFICILE INFECTION (CDI) SURVEILLANCE EMERGING INFECTIONS PROGRAM CASE REPORT Form and Instruction	Modified
207663	FoodNet Variable List, 2024_ (YERSINIA) Form and Instruction	Unchanged
207662	FoodNet Variable List, 2024_ (VIBRIO) Form and Instruction	Unchanged
207661	FoodNet Variable List, 2024_ (SHIGELLA) Form and Instruction	Unchanged
207660	FoodNet Variable List, 2024_ (SHIGA TOXIN PRODUCING E.COLI) Form and Instruction	Unchanged
207659	FoodNet Variable List, 2024_ (SALMONELLA) Form and Instruction	Unchanged
207658	FoodNet Variable List, 2024_ (LISTERIA MONOCTOGENES) Form and Instruction	Unchanged
207657	FoodNet Variable List, 2024_ (CYCLOSPORA) Form and Instruction	Unchanged
207655	FoodNet Variable List, 2024_(CAMPYLOBACTER) Form and Instruction	Unchanged
207653	FLUSURV-NET: CONSENT FORM FOR PATIENT/PROXY INTERVIEW (English/Spanish) Form and Instruction	Unchanged
207652	FoodNet Hemolytic Uremic Syndrome (HUS) Form and Instruction	Modified
207651	FluSurv-Net Influenza Hospitalization Surveillance Network Case Report Form Form and Instruction	Unchanged
207649	Active Bacterial Core Surveillance (ABCs) Neonatal Infection Expanded Tracking Form Form and Instruction	Unchanged
207648	ABCs Invasive Pneumococcal Disease in Children and Adults Form and Instruction	Unchanged
207646	2024 Active Bacterial Core Surveillance (ABCs) Case Report Form and Instruction	Unchanged