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 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	Food Record	Att 12A_Food Record Form_01082014.docx		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	Att 12B_Food Record Instructions_01082014.docx	01/09/2014

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