Health Survey

Morbidity Study of Former Marines, Dependents, and Employees Potentially Exposed to Contaminated Drinking Water at USMC Base Camp Lejeune

Documents and Forms

Document Name Document Type
Health Survey Form
Health Survey Attachment C Marine Health Survey April 2011.docx Form
Attachment D prenotice and invite ltr USMC 2_11 clean.docx Att D - Invitation Letter IC Document
Attachment F email invite 2_11 clean.doc Att F - Email Invitation IC Document
Attachment G postcard 2_11 clean.doc Att G - Postcard Reminder/Thank you IC Document
Attachment H email reminder 2_11 clean.doc Att H - Email Reminder/Thank you IC Document
Attachment I reminder letter 2_11 clean.doc Att I - Reminder Letter IC Document
Attachment J email reminder 2_11 clean.doc AttJ - Email Reminder IC Document
Attachment K telephone reminder 2_11 clean.doc Att K - Telephone Reminder IC Document
Attachment L Consent for Health Study participnats April 2011.doc Att L - Participant Consent IC Document
Attachment M Consent for registrants April 2011 redline.doc Att M - Registrant Consent IC Document
Attachment E Letters of invitation from ATSDR April 2011.doc Attachment E Letters of invitation from ATSDR April 2011 IC Document

Information Collection (IC) Details

IC Title:	Health Survey	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	none	Health Survey	Attachment C Marine Health Survey April 2011.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 47,601	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

	Approved	Previously Approved
Annual Number of Responses for this IC	47,601	47,601
Annual IC Time Burden (Hours)	35,701	35,701
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att D - Invitation Letter	Attachment D prenotice and invite ltr USMC 2_11 clean.docx	04/14/2011
Att F - Email Invitation	Attachment F email invite 2_11 clean.doc	04/14/2011
Att G - Postcard Reminder/Thank you	Attachment G postcard 2_11 clean.doc	04/14/2011
Att H - Email Reminder/Thank you	Attachment H email reminder 2_11 clean.doc	04/14/2011
Att I - Reminder Letter	Attachment I reminder letter 2_11 clean.doc	04/14/2011
AttJ - Email Reminder	Attachment J email reminder 2_11 clean.doc	04/14/2011
Att K - Telephone Reminder	Attachment K telephone reminder 2_11 clean.doc	04/14/2011
Att L - Participant Consent	Attachment L Consent for Health Study participnats April 2011.doc	04/14/2011
Att M - Registrant Consent	Attachment M Consent for registrants April 2011 redline.doc	04/14/2011
Attachment E Letters of invitation from ATSDR April 2011	Attachment E Letters of invitation from ATSDR April 2011.doc	04/25/2011

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