Information Collection

Healthcare Worker-Ebola Virus Disease Investigation Questionnaire - Liberia

IC 214672 under ICR 201501-0920-017 · OMB 0920-1033.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1033 Healthcare Worker-Ebola Virus Disease Investigation Questionnaire - Liberia	Form and Instruction
0920-1033 Att C HCW.Ebola.virus.invest.questionnaire_Liberia Att C HCW.Ebola.virus.invest.questionnaire_Liberia.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-103315LC

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	0920-1033	Att C HCW.Ebola.virus.invest.questionnaire_Liberia	Att C HCW.Ebola.virus.invest.questionnaire_Liberia.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 100

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	100	100
Annual IC Time Burden (Hours)	50	50
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.