ALS One-time Survey

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⚠️ Notice: This information collection may be referencing outdated material.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 One-time Survey Form
6a - Previously approved surveys Attach_6a-Screen Shots_Previously Approved Surveys-v2.docx Form
6b - New Surveys Attach_6b-Screen Shots New Surveys-V2.docx Form

Information Collection (IC) Details

IC Title:	ALS One-time 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	6a - Previously approved surveys	Attach_6a-Screen Shots_Previously Approved Surveys-v2.docx		Yes	Yes	Fillable Fileable
Form	none	6b - New Surveys	Attach_6b-Screen Shots New Surveys-V2.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	FR Citation: 59 FR 67085

Number of Respondents: 750	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	12,000	-2,004	14,004
Annual IC Time Burden (Hours)	1,000	-167	1,167
Annual IC Cost Burden (Dollars)	0	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.