Information Collection

Health Facility Assessment and Case Finding Survey

IC 213621 under ICR 201501-0920-017 · OMB 0920-1033.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-15CN Health Facility Assessment and Case Finding Survey	Form and Instruction
0920-15CN Attachment M_Health Facility Assessment and Case Finding Attachment M_Health Facility Assessment and Case Finding Survey.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-15CN

Is this a Common Form? No

IC Status: Unchanged

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	0920-15CN	Attachment M_Health Facility Assessment and Case Finding Survey	Attachment M_Health Facility Assessment and Case Finding Survey.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Ebola Emergency Investigation Case Records Systems Notice

FR Citation: 51 FR 42466

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	150	150
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.