ALS Registration

National Amyotrophic Lateral Sclerosis (ALS) Registry

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0041 can be found here:

Documents and Forms

Document Name Document Type
ALS Registration Form
ALS Registry Registration Attach_5-Screen Shot Registration Page.docx Form
Attachment 8 - Screen Shot Consent Form-revised.docx 8 - Consent Form IC Document

Information Collection (IC) Details

IC Title:	ALS Registration	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	ALS Registry Registration	Attach_5-Screen Shot Registration Page.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances, 09-19-0001	FR Citation: 59 FR 67085

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	Previously Approved
Annual Number of Responses for this IC	1,500	-3,167	4,667
Annual IC Time Burden (Hours)	175	-369	544
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
8 - Consent Form	Attachment 8 - Screen Shot Consent Form-revised.docx	05/02/2013

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