Information Collection

Symptom Monitoring Form - Health Care Workers

IC 214552 under ICR 201501-0920-006 · OMB 0920-1045.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Symptom Monitoring Form - Health Care Workers	Form and Instruction
Symptom Monitoring Form Att6 Symptom Monitoring Form.docx	Form and Instruction

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 and Instruction	None	Symptom Monitoring Form	Att6 Symptom Monitoring Form.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records

Title: 09-20-0113, Epidemic Investigation Case Record Systems Notice

FR Citation: 51 FR 42466

Number of Respondents: 300

Number of Respondents for Small Entity: 300

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12,600	12,600
Annual IC Time Burden (Hours)	1,050	1,050
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.