Information Collection

Ebola Exposure Questionnaire for Cleaning Crew

IC 213969 under ICR 201411-0920-006 · OMB 0920-1032.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Ebola Exposure Questionnaire for Cleaning Crew	Form
Ebola Exposure Questionnaire for Cleaning Crew Attachment D ExposureQuestionnaire_CleaningCrew.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	Ebola Exposure Questionnaire for Cleaning Crew	Attachment D ExposureQuestionnaire_CleaningCrew.docx	None	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.