Information Collection

Adult Case Subjects Telephone Interview

IC 210428 under ICR 201406-0920-019 · OMB 0920-1013.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920 Adult Case Subjects Telephone Interview	Form and Instruction
0920 Attachment F_Adult Interview Form Attachment F_Adult Interview Form 1_24_14.docx	Form and Instruction
SPANISH TRANSLATION_Attachment M_CA CDI Adult_ Patient Interview Form_1_24_14.doc SPANISH TRANSLATION_Attachment M_CA CDI Adult_ Patient Interview Form	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301

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 and Instruction	0920	Attachment F_Adult Interview Form	Attachment F_Adult Interview Form 1_24_14.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 71

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	71	71
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SPANISH TRANSLATION_Attachment M_CA CDI Adult_ Patient Interview Form	SPANISH TRANSLATION_Attachment M_CA CDI Adult_ Patient Interview Form_1_24_14.doc	02/17/2014

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