Health Questionnaire

Factors Influencing the Transmission of Influenza

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0888 can be found here:

Documents and Forms

Document Name Document Type
Health Questionnaire Form
Health Questionnaire Attachment 5 - Health Questionnaire.docx Form

Information Collection (IC) Details

IC Title:	Health Questionnaire	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	Health Questionnaire	Attachment 5 - Health Questionnaire.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Occupational Health Epidemiological Studies and EEOICPA Records	FR Citation: 76 FR 34706

Number of Respondents: 180	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	180	140	40
Annual IC Time Burden (Hours)	15	8	7
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.