Information Collection

ALS Case Reporting Form

IC 196097 under ICR 201111-0923-002 · OMB 0923-0043.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0043 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ALS Case Reporting Form	Form
Case Reporting Form Attachment 3 -case report form for training-3-31-11-final.docx	Form

IC Title:

ALS Case Reporting Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	Case Reporting Form	Attachment 3 -case report form for training-3-31-11-final.docx		No	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 57 FR 62712

Number of Respondents: 2,250

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,250	2,250
Annual IC Time Burden (Hours)	188	188
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.