Information Collection

42 CFR 70.3 Copy of Materials (Applicant/Attending Physician)

IC 185655 under ICR 201002-0920-009 · OMB 0920-0488.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0488 can be found here:

Documents and Forms

Document Name Document Type
Att 4_Multi-Purpose Application.doc Other-WORD
09-20-0171.pdf SORN 09-20-0171 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	42 CFR 70.3 Copy of Materials (Applicant/Attending Physician)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			Att 4_Multi-Purpose Application.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Quarantine and Traveler-Related Activities, Including Records for Contact Tracing, Investigation, and Notification under 42 CFR Parts 70 and 71	FR Citation: 72 FR 70867

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SORN 09-20-0171	09-20-0171.pdf	06/25/2008

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.