Active Monitoring Survey - French

Emergency Submission to Supplement OMB Control Number 0920-0821 in the Context of Active Monitoring of Travelers Coming from Sierra Leone, Liberia, and Guinea

Documents and Forms

Document Name Document Type
Active Monitoring Survey - French Form and Instruction
Active Monitoring Survey - French Attachment C French script.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Active Monitoring Survey - French	Agency IC Tracking Number:

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	none	Active Monitoring Survey - French	Attachment C French script.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Quarantine and Traveler Related Activities	FR Citation: 72 FR 70867

Number of Respondents: 4,562	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	95,802	95,802
Annual IC Time Burden (Hours)	6,387	6,387
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.