Information Collection

Case Questionnaire

IC 197042 under ICR 201105-0920-003 · OMB 0920-0905.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0905 can be found here:

Documents and Forms

Document Name Document Type
Form Case Questionnaire Case Questionnaire Form
Case Questionnaire case Questionnaire Case Questionnaire_10-31-11.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Case Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Case Questionnaire	case Questionnaire	Case Questionnaire_10-31-11.doc		No		Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 161	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	161	161
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	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.