Ebola Virus Disease Case Contact Questionnaire

2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1033 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-15CN Ebola Virus Disease Case Contact Questionnaire Form and Instruction
0920-15CN Attachment L_Ebola Virus Disease Case Contact Questionna Attachment L_Ebola Virus Disease Case Contact Questionnaire.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Ebola Virus Disease Case Contact Questionnaire	Agency IC Tracking Number:	0920-15CN

Is this a Common Form? No		IC Status: New

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 and Instruction	0920-15CN	Attachment L_Ebola Virus Disease Case Contact Questionnaire	Attachment L_Ebola Virus Disease Case Contact Questionnaire.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Ebola Emergency Investigation Case Records System Notice	FR Citation: 51 FR 42166

Number of Respondents: 50	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
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	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.