OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

2014016-XXX_Ebola_DRC

IC 212908 under ICR 201504-0920-005 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2014016-XXX_Appendix 2--CONTACT LISTING FORM.pdf	Other-WORD
2014016-XXX_Appendix 1--CASE REPORT FORM.pdf	Other-WORD
2014016-XXX_Ebola_DRC.docx Request for Approval 2014016-XXX_Ebola_DRC	IC Document
2014016-XXX_ Letter of Invitation DRC MOH_Ebola Outbreak Equateur Province (1).pdf Invitation Letter	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

2014016-XXX_Ebola_DRC

Agency IC Tracking Number:

14AXM

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
Other-WORD			2014016-XXX_Appendix 2--CONTACT LISTING FORM.pdf		No		Fillable Printable
Other-WORD			2014016-XXX_Appendix 1--CASE REPORT FORM.pdf		No		Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	1,200	0	0	0	0	1,200
Annual IC Time Burden (Hours)	134	0	0	0	0	134
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval 2014016-XXX_Ebola_DRC	2014016-XXX_Ebola_DRC.docx	09/02/2014
Invitation Letter	2014016-XXX_ Letter of Invitation DRC MOH_Ebola Outbreak Equateur Province (1).pdf	09/03/2014

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