Healthcare Worker-Ebola Virus Disease Investigation Questionnaire - Liberia

2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Healthcare Worker-Ebola Virus Disease Investigation Questionnaire - Liberia	Agency IC Tracking Number:	0920-103315LC

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 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 %

	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

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.