United States Traveler Health Declaration - ENGLISH

Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
United States Traveler Health Declaration - ENGLISH Form and Instruction
United States Traveler Health Declaration - English/Hard Attachment F1a 2015 01 23 Health Declaration clean.doc Form and Instruction
United States Traveler Health Declaration - English/Port Attachment F1b United States Traveler Health Declaration - Portal.png Form and Instruction
United States Health Declaration - English/PDF Attachment F1c 2015 01 12 Health Declaration - Fillable PDF.PDF Form and Instruction

Information Collection (IC) Details

IC Title:	United States Traveler Health Declaration - ENGLISH	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 and Instruction	None	United States Traveler Health Declaration - English/Hard Copy	Attachment F1a 2015 01 23 Health Declaration clean.doc	None	Yes	Yes	Fillable Fileable
Form and Instruction	None	United States Traveler Health Declaration - English/Portal	Attachment F1b United States Traveler Health Declaration - Portal.png	None	Yes	Yes	Fillable Fileable
Form and Instruction	None	United States Health Declaration - English/PDF	Attachment F1c 2015 01 12 Health Declaration - Fillable PDF.PDF	None	Yes	Yes	Fillable Fileable

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	FR Citation: 72 FR 7086

Number of Respondents: 49,238	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	49,238	49,238
Annual IC Time Burden (Hours)	12,310	12,310
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.