Ebola Exposure Questionnaire for Cleaning Crew

Emergency Submission to Supplement OMB Control Number 0920-0900 in Context of Contact Investigations Associated with Ebola and Travel

Documents and Forms

Document Name Document Type
Ebola Exposure Questionnaire for Cleaning Crew Form
Ebola Exposure Questionnaire for Cleaning Crew Attachment D ExposureQuestionnaire_CleaningCrew.docx Form

Information Collection (IC) Details

IC Title:	Ebola Exposure Questionnaire for Cleaning Crew	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	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 %

	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

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.