ALS Medical Record Verification Form

Creation of State and Metropolitan Area Based Surveillance Projects for Amyotrophic Lateral Sclerosis (ALS)

OMB: 0923-0043

IC ID: 196098

Information Collection (IC) Details

View Information Collection (IC)

ALS Medical Record Verification Form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form none Medical Record Verification Form Attachment 4 Medical Record Verification Form (2).docx No No Printable Only

Health Public Health Monitoring

Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances  57 FR 62712

450 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 450 0 0 0 0 450
Annual IC Time Burden (Hours) 150 0 0 0 0 150
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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