Information Collection

Worksheet for Identifying Medical Conditions among Refugees and Immigrants

IC 181025 under ICR 200707-0920-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Worksheet for Identifying Medical Conditions among Refugees and Immigrants	Form and Instruction
Worksheet for Identifying Medical Conditions among Refug Attachment 4. Worksheet and Instructions.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Worksheet for Identifying Medical Conditions among Refugees and Immigrants	Attachment 4. Worksheet and Instructions.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 0920-0136, Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51,000	51,000
Annual IC Time Burden (Hours)	4,250	4,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.