Information Collection

United States Traveler Health Declaration - ENGLISH

IC 214888 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

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	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 %

table that charts list of burden
	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

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.