OMB control number

[NCEZID] Characteristics of Cases of Priority Fungal Diseases

OMB 0920-1385 · HHS/CDC.

OMB 0920-1385

For patients involving triazole-resistant A. fumigatus isolates detected through passive public health surveillance, we will use a standardized case report form to collect public health surveillance data regarding demographics, underlying medical conditions, treatments, and outcomes. Health departments would be asked to voluntarily fill out the de-identified form. Proposed changes for this Revision include the addition of five new CRFs and changes to a current form.

The latest form for [NCEZID] Characteristics of Cases of Priority Fungal Diseases expires 2028-02-29 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 0920-1385 Sporotrichosis case report form Form
Form 0920-1385 Mycetoma case report form Form
Form 0920-1385 Chromoblastomycosis case report form Form
Form 0920-1385 Antifungal-resistant dermatophytosis case report form Form
Form 0920-1385 Candida auris Case Report Form Form
Form 0920-1385 Blastomycosis Case Report Form Form
Form 0920-1385 Histoplasmosis Case Report Form Form
Form 0920-1385 Coccidioidomycosis Case Report Form Form
Form 0920-1385 Triazole-resistant Aspergillus fumigatus Case Report Form Form
Att 1 Section 301 of the Public Health Service Act (42 USC 241).pdf Supplementary Document
Att. 4 Non Research Determination.pdf Supplementary Document
Att. 5- Privacy Impact Assessment.pdf Supplementary Document
Att 4- Human Subjects Determination.pdf Supplementary Document
Att 2-Published 60-day FRN.pdf Supplementary Document
Att 1 Section 301 of the Public Health Service Act (42 USC 241).pdf Supplementary Document
SSB FungiSurv1_Revision_FINAL.docx Supporting Statement B
SSA FungiSurv1_Revision_FINAL.docx Supporting Statement A
Sporotrichosis case report form Form
Mycetoma case report form Form
Chromoblastomycosis case report form Form
Antifungal-resistant dermatophytosis case report form Form
Candida auris Case Report Form Form
Blastomycosis Case Report Form Form
Histoplasmosis Case Report Form Form
Coccidioidomycosis Case Report Form Form
Triazole-resistant Aspergillus fumigatus Case Report Form Form

All Historical Document Collections

202501-0920-004	Revision of a currently approved collection	2025-01-16
202402-0920-008 Approved with change	Revision of a currently approved collection	2024-03-14
202205-0920-013 Approved without change	New collection (Request for a new OMB Control Number)	2022-06-07

OMB Details

Triazole-resistant Aspergillus fumigatus Case Report Form

Federal Enterprise Architecture: Health - Public Health Monitoring

Form 0920-1385

Triazole-resistant Aspergillus fumigatus case reporting

Fillable Fileable

Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.