OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

2014012-XXX Resp Illness UC_CA

IC 212320 under ICR 201501-0920-020 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix 1. Interview Form.docx	Other-WORD
2014012-XXX_Resp Illness UC_CA.docx	Other-WORD
FW CDC Epi Aid request received from ORR.msg	Other-Email

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

2014012-XXX Resp Illness UC_CA

Agency IC Tracking Number:

15AOH

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
Other-WORD			Appendix 1. Interview Form.docx		Yes	Yes	Fillable Printable
Other-WORD			2014012-XXX_Resp Illness UC_CA.docx		Yes	Yes	Fillable Printable
Other-Email			FW CDC Epi Aid request received from ORR.msg		No		Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	250	0	0	0	0	250
Annual IC Time Burden (Hours)	83	0	0	0	0	83
Annual IC Cost Burden (Dollars)	0	0	0	0	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.