Information Collection

Questionnaire for Ebola-Affected Households

IC 214717 under ICR 201501-0920-021 · OMB 0920-1043.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Questionnaire for Ebola-Affected Households	Form and Instruction
Questionnaire for Ebola-affected Households Att2 Questnnre for Ebola HHs 20150118.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	Questionnaire for Ebola-affected Households	Att2 Questnnre for Ebola HHs 20150118.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records

Title: 09-20-0113 Epi Invest Case Records

FR Citation: 51 FR 42466

Number of Respondents: 119

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	119	119
Annual IC Time Burden (Hours)	40	40
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.