Information Collection

Illness Checklist

IC 198576 under ICR 201112-0920-013 · OMB 0920-0906.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0906 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Illness Checklist	Form
Illness Checklist Appendix D9 - Illness Checklist (Children 7-12 years) 5-10-11.doc	Form
Appendix D9 - Illness Checklist (Children 7-12 years) 5-10-11_CHN7.30.2011.doc Illness checklist - Chinese	IC Document
Appendix D9 - Illness Checklist (Children 7-12 years) 5-10-11 SPANISH.docx Illness Checklist - Spanish	IC Document

IC Title:

Illness Checklist

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	Illness Checklist	Appendix D9 - Illness Checklist (Children 7-12 years) 5-10-11.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Epidemiological Studies and Surveillance of Disease Problems 09-20-0136

FR Citation: 57 FR 62812

Number of Respondents: 832

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	Previously Approved
Annual Number of Responses for this IC	3,328	3,328
Annual IC Time Burden (Hours)	277	277
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Illness checklist - Chinese	Appendix D9 - Illness Checklist (Children 7-12 years) 5-10-11_CHN7.30.2011.doc	12/14/2011
Illness Checklist - Spanish	Appendix D9 - Illness Checklist (Children 7-12 years) 5-10-11 SPANISH.docx	12/14/2011

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