Information Collection

Lost to Follow-up

IC 193184 under ICR 201006-0930-001 · OMB 0930-0312.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form K - Dx Int Lo Lost to Follow-up	Form and Instruction
Form K - Dx Int Lo Form K - Dx Int Lost Follow-up K- Dx Int Lost Follup.doc	Form and Instruction
Consent forms.pdf Consent Forms	IC Document

IC Title:

Lost to Follow-up

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	Form K - Dx Int Lost Follow-up	Form K - Dx Int Lost Follow-up	K- Dx Int Lost Follup.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Forms	Consent forms.pdf	05/27/2010

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