International Maritime Illness or Death Investigation

Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0821 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0821 International Maritime Illness or Death Investigation Form and Instruction
0920-0821 Attachment A Maritime investigation form Attachment A Maritime investigation form_June22 2012.docx Form and Instruction
Attachment B 71 21a Other illness reports MIDRS screenshot.pdf Attachment B 71 21a Other illness reports MIDRS screenshot IC Document

Information Collection (IC) Details

IC Title:	International Maritime Illness or Death Investigation	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	0920-0821	Attachment A Maritime investigation form	Attachment A Maritime investigation form_June22 2012.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Quarantine and Traveler Related Activities, including Records for Contact Tracing Investigation and Notification	FR Citation: 72 FR 70867

Number of Respondents: 1,873	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,873	0	1,873
Annual IC Time Burden (Hours)	156	-63	219
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment B 71 21a Other illness reports MIDRS screenshot	Attachment B 71 21a Other illness reports MIDRS screenshot.pdf	03/29/2013

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