Information Collection

International Maritime Illness or Death Investigation

IC 187997 under ICR 201502-0920-002 · OMB 0920-0821.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0821 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0821 International Maritime Illness or Death Investigation	Form and Instruction
0920-0821 Attachment A Maritime investigation form Attachment A Maritime investigation form_June22 2012.docx	Form and Instruction
Attachment B 71 21a Other illness reports MIDRS screenshot.pdf Attachment B 71 21a Other illness reports MIDRS screenshot	IC Document

IC Title:

International Maritime Illness or Death Investigation

Agency IC Tracking Number:

Is this a Common Form? No

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
Form and Instruction	0920-0821	Attachment A Maritime investigation form	Attachment A Maritime investigation form_June22 2012.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Quarantine and Traveler Related Activities, including Records for Contact Tracing Investigation and Notification

FR Citation: 72 FR 70867

Number of Respondents: 1,873

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,873	1,873
Annual IC Time Burden (Hours)	156	156
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment B 71 21a Other illness reports MIDRS screenshot	Attachment B 71 21a Other illness reports MIDRS screenshot.pdf	03/29/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.