Information Collection

Serologic Survey for Vibrio cholerae Infection in Haiti with Assessment of Risk Factors for Asymptomatic, Mild, Moderate, and Severe Disease

IC 195978 under ICR 201101-0920-003 · OMB 0920-0877.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Serologic Survey for Vibrio cholerae Infection in Haiti with Assessment of Risk Factors for Asymptomatic, Mild, Moderate, and Severe Disease	Form and Instruction
1 Survey Instrument Appendix Questionnaires 1-10-11.docx	Form and Instruction
Appendix Consent Forms.docx Appendix Consent Forms	IC Document

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	1	Survey Instrument	Appendix Questionnaires 1-10-11.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix Consent Forms	Appendix Consent Forms.docx	01/18/2011

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