Hazardous Substances Emergency Events Surveillance

Documents and Forms

Document Name Document Type
appendix 3b - hsees-datacollection-form05.pdf Other-Surveillance Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hazardous Substances Emergency Events Surveillance	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 103

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Surveillance Form			appendix 3b - hsees-datacollection-form05.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,504	-1,996	9,500
Annual IC Time Burden (Hours)	5,628	-422	6,050
Annual IC Cost Burden (Dollars)	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.