Information Collection

Patient Laboratory Record

IC 214720 under ICR 201501-0920-021 · OMB 0920-1043.

Documents and Forms

Document Name Document Type
Patient Laboratory Record Form
Patient Laboratory Record Att6 Patient Lab Record 20150118.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patient Laboratory Record	Agency IC Tracking Number:

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	None	Patient Laboratory Record	Att6 Patient Lab Record 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: 191	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	191	191
Annual IC Time Burden (Hours)	16	16
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.