Ebola Entry Screening Risk Assessment (Ill Traveler Interview)

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⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

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:

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 %

	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

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.