Katrina and Rita Exposures Registry - questionnaire

Registration of Individuals Displaced by Hurricanes Katrina and Rita (Pilot Project)

Documents and Forms

Document Name Document Type
Katrina and Rita Exposures Registry - questionnaire Form and Instruction
Quesitonaire Appendix F Main Questionnaire 20130130.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Katrina and Rita Exposures Registry - 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 and Instruction	none	Quesitonaire	Appendix F Main Questionnaire 20130130.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Records of Persons Exposed to or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 53 FR 30720

Number of Respondents: 1,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	450	450
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.