Information Collection

Ebola Entry Screening Risk Assessment (Ill Traveler Interview)

IC 214908 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⚠️ Notice: This information collection may be referencing outdated material.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
Ebola Entry Screening Risk Assessment (Ill Traveler Interview)	Form and Instruction
Ebola Entry Screening Risk Assessment Form - English Attachment G1 CDC Form Ebola Risk Assessment 05FEB2015.docx	Form and Instruction
Ebola Entry Screening Risk Assessment Form - French Attachment G2 CDC Form Ebola Risk Assessment Trans Guide French.docx	Form and Instruction
Ebola Entry Screening Risk Assessment Form - Arabic Attachment G3 CDC Form Ebola Risk Assessment Trans Guide Arabic.doc	Form and Instruction

IC Title:

Ebola Entry Screening Risk Assessment (Ill Traveler Interview)

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?	Electronic Capability
Form and Instruction	None	Ebola Entry Screening Risk Assessment Form - English	Attachment G1 CDC Form Ebola Risk Assessment 05FEB2015.docx	None	No	Paper Only
Form and Instruction	None	Ebola Entry Screening Risk Assessment Form - French	Attachment G2 CDC Form Ebola Risk Assessment Trans Guide French.docx	None	No	Paper Only
Form and Instruction	None	Ebola Entry Screening Risk Assessment Form - Arabic	Attachment G3 CDC Form Ebola Risk Assessment Trans Guide Arabic.doc	None	No	Paper Only

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: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	25	25
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.