2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities

Forms and Documents

Document Name	Status
Form 0920-1033 Healthcare Worker- Ebola Virus Disease Exposure Risk Report - Sierra Leone Form and Instruction	New
Form 0920-1033 Healthcare Worker-Ebola Virus Disease Investigation Questionnaire - Liberia Form and Instruction	New
Form 0920-1033 Healhcare Worker-Ebola Virus Disease Exposure Risk Report (CDC/WHO) - French Form and Instruction	New
Form 0920-1033 Healthcare Worker-Ebola Virus Disease Exposure Risk Report (CDC/WHO) Form and Instruction	New
Form 0920-15CN Health Facility Assessment and Case Finding Survey Form and Instruction	Unchanged
Form 0920-15CN Ebola Virus Disease Case Contact Questionnaire Form and Instruction	Unchanged
Form 0920-15CN Viral Hemorrhagic Fever Contact Tracing Follow-Up Form Form and Instruction	Unchanged
Form 0920-15CN Viral Hemorrhagic Fever Contact Listing Form (Liberia) Form and Instruction	Unchanged
Form 0920-15CN Viral Hemorrhagic Fever Contact Listing Form (Guinea French) Form and Instruction	Unchanged
Form 0920-15CN Viral Hemorrhagic Fever Contact Listing Form (Senegal French) Form and Instruction	Unchanged
Form 0920-15CN Viral Hemorrhagic Fever Contact Listing Form (General) Form and Instruction	Unchanged
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Short Version Liberia) Form and Instruction	Unchanged
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Nigeria) Form and Instruction	Unchanged
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Sierra Leone) Form and Instruction	Unchanged
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Liberia) Form and Instruction	Unchanged
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Senegal French) Form and Instruction	Unchanged
Form 0920-15CN Viral Hemorrhagic Fever Case Investigation Form (Guinea French) Form and Instruction	Unchanged
non-Substantive Change Request to 0920-1033 1-14-15.docx Justification for No Material/Nonsubstantive Change	2015-01-16
Attachment O_Ebola Virus Epi Invest SORN_10-06-2014.doc Supplementary Document	2014-10-23
International_Ebola Emergency Clearance SSA Final.docx Supporting Statement B	2014-10-23
International_Ebola Emergency Clearance SSA Final.docx Supporting Statement A	2014-10-23

IC Document Collections

IC ID	Document Title	Status
214673	Healthcare Worker- Ebola Virus Disease Exposure Risk Report - Sierra Leone Form and Instruction	New
214672	Healthcare Worker-Ebola Virus Disease Investigation Questionnaire - Liberia Form and Instruction	New
214671	Healhcare Worker-Ebola Virus Disease Exposure Risk Report (CDC/WHO) - French Form and Instruction	New
214670	Healthcare Worker-Ebola Virus Disease Exposure Risk Report (CDC/WHO) Form and Instruction	New
213621	Health Facility Assessment and Case Finding Survey Form and Instruction	Unchanged
213620	Ebola Virus Disease Case Contact Questionnaire Form and Instruction	Unchanged
213619	Viral Hemorrhagic Fever Contact Tracing Follow-Up Form Form and Instruction	Unchanged
213618	Viral Hemorrhagic Fever Contact Listing Form (Liberia) Form and Instruction	Unchanged
213617	Viral Hemorrhagic Fever Contact Listing Form (Guinea French) Form and Instruction	Unchanged
213616	Viral Hemorrhagic Fever Contact Listing Form (Senegal French) Form and Instruction	Unchanged
213615	Viral Hemorrhagic Fever Contact Listing Form (General) Form and Instruction	Unchanged
213614	Viral Hemorrhagic Fever Case Investigation Form (Short Version Liberia) Form and Instruction	Unchanged
213613	Viral Hemorrhagic Fever Case Investigation Form (Nigeria) Form and Instruction	Unchanged
213612	Viral Hemorrhagic Fever Case Investigation Form (Sierra Leone) Form and Instruction	Unchanged
213611	Viral Hemorrhagic Fever Case Investigation Form (Liberia) Form and Instruction	Unchanged
213609	Viral Hemorrhagic Fever Case Investigation Form (Senegal French) Form and Instruction	Unchanged
213607	Viral Hemorrhagic Fever Case Investigation Form (Guinea French) Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-1033	ICR Reference No: 201501-0920-017
Status: Historical Active	Previous ICR Reference No: 201410-0920-027
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-15CN
Title: 2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 10/24/2014
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/16/2015
	Date Received in OIRA: 01/16/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2015	6 Months From Approved	04/30/2015
Responses	298,650	0	297,850
Time Burden (Hours)	54,679	0	54,279
Cost Burden (Dollars)	0	0	0

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Abstract: CDC is requesting a non-substantive change request to add four forms, one which was previously approved under the Epi-Aid Mechanism, 0920-1011 and expired 12/31/14: Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO). There are three new forms: Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO) – French, Healthcare Worker - Ebola Virus Disease Investigation Questionnaire – Liberia, and Healthcare Worker - Ebola Virus Disease Exposure Risk Report - Sierra Leone.

Emergency Justfication: WHO has declared the Ebola outbreak in West Africa to be an international public health emergency. The 2014 Ebola outbreak is unprecedented and the first in West Africa. CDC is currently assisting with the investigation, by taking active steps to respond to the rapidly changing situation internationally and domestically by working with other U.S. government agencies, the World Health Organization, and other domestic and international partners to identify sources and risk factors for Ebola infection in order to implement prevention and control measures. The epidemiological objectives are to maintain a centralized database for data collected from all outbreak sites, domestic and international to assist in contact tracing, case report collection, and patient or family interviews.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 17

IC Title	Form No.	Form Name
Viral Hemorrhagic Fever Case Investigation Form (Senegal French)	0920-15CN	Attachment C_Viral Hemorrhagic Fever Case Investigation Form_Senegal_French
Viral Hemorrhagic Fever Case Investigation Form (Liberia)	0920-15CN	Attachment D_Viral Hemorrhagic Fever Case Investigation Form_Liberia (2)
Ebola Virus Disease Case Contact Questionnaire	0920-15CN	Attachment L_Ebola Virus Disease Case Contact Questionnaire
Health Facility Assessment and Case Finding Survey	0920-15CN	Attachment M_Health Facility Assessment and Case Finding Survey
Viral Hemorrhagic Fever Case Investigation Form (Guinea French)	0920-15CN	Attachment B_Viral Hemorrhagic Fever Case Investigation Form_Guinea_French
Viral Hemorrhagic Fever Case Investigation Form (Sierra Leone)	0920-15CN	Attachment E_Viral Hemorrhagic Fever Case Investigation Form_Sierra Leone
Viral Hemorrhagic Fever Case Investigation Form (Short Version Liberia)	0920-15CN	Attachment G_Viral Hemorrhagic Fever Case Investigation Form_Short Version_Liberia
Viral Hemorrhagic Fever Case Investigation Form (Nigeria)	0920-15CN	Attachment F_Viral Hemorrhagic Fever Case Investigation Form_Nigeria
Viral Hemorrhagic Fever Contact Listing Form (General)	0920-15CN	Attachment H_Viral Hemorrhagic Fever Contact Listing Form_General
Viral Hemorrhagic Fever Contact Listing Form (Senegal French)	0920-15CN	Attachment I_Viral Hemorrhagic Fever Contact Listing Form_Senegal_French
Viral Hemorrhagic Fever Contact Listing Form (Guinea French)	0920-15CN	Attachment J_Viral Hemorrhagic Fever Contact Listing Form_Guinea_French
Viral Hemorrhagic Fever Contact Listing Form (Liberia)	0920-15CN	Attachment K_Viral Hemorrhagic Fever Contact Listing Form_Liberia
Viral Hemorrhagic Fever Contact Tracing Follow-Up Form	0920-15CN	Attachment N_Viral Hemorrhagic Fever Contact Tracing Follow-Up Form
Healthcare Worker-Ebola Virus Disease Exposure Risk Report (CDC/WHO)	0920-1033	Att A HCW.EVD.expriskreport_WestAfrica
Healthcare Worker-Ebola Virus Disease Investigation Questionnaire - Liberia	0920-1033	Att C HCW.Ebola.virus.invest.questionnaire_Liberia
Healthcare Worker- Ebola Virus Disease Exposure Risk Report - Sierra Leone	0920-1033	Att D HCW.EVD.expriskreport_SierraLeone
Healhcare Worker-Ebola Virus Disease Exposure Risk Report (CDC/WHO) - French	0920-1033, 0920-1033	Att B HCW.EVD.expriskreport_WestAfrica v10 French ,   Att B1 HCW.EVD.expriskreport_WestAfrica v10 Eng Translation

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	298,650	297,850	0	800	0	0
Annual Time Burden (Hours)	54,679	54,279	0	400	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: CDC is requesting a non-substantive change request to add four forms, one which was previously approved under the Epi-Aid Mechanism, 0920-1011 and expired 12/31/14: Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO). There are three new forms: Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO) – French, Healthcare Worker - Ebola Virus Disease Investigation Questionnaire – Liberia, and Healthcare Worker - Ebola Virus Disease Exposure Risk Report - Sierra Leone. The purpose of these forms is to investigate cases of Ebola Virus Disease in health care workers to determine what facility-based risk factors may have led to their infection, to allow for corrective changes in health care facility infection prevention practices and to contribute to epidemiologic understanding of the Ebola epidemic in order to combat it more effectively. These forms were developed through a consultative process between the national Ministry of Health and implementing partners, based on experience piloting earlier versions. CDC was involved as a consultant in its development. The request for multiple forms with small differences for each country in which they will be deployed reflects the reality on the ground. The total approved hours in this collection is 54,282.

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Annual Cost to Federal Government: $339,695

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/16/2015

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