Information Collection

Food Record Form

IC 207195 under ICR 201401-0920-004 · OMB 0920-0982.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Food Record Food Record Form	Form
Food Record Att 12A_Food Record Form_01082014.docx	Form
Att 12B_Food Record Instructions_01082014.docx Food Record Instructions	IC Document

IC Title:

Food Record Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none				Yes	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 252

Number of Respondents: 225

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	225	225
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Food Record Instructions		01/09/2014

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

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