Information Collection

Monkeypox_ROC

IC 217356 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⚠️ Notice: This information collection may be referencing outdated material.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
Monkeypox_ROC	Form
Survey iin English Appendix 1a. Risk Factor Assessment_French.doc	Form
Survey in French Appendix 1a. Risk Factor Assessment_French.doc	Form
2015010-XXX_Monkeypox_Congo.docx Request for Approval	IC Document
Invitation Letter - translated.docx Invitation Letter Translated	IC Document
Invitation letter_6 24 2015.jpg Invitation Letter in French	IC Document

IC Title:

Monkeypox_ROC

Agency IC Tracking Number:

15AUD

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR Public Health Service Act (To search for a specific CFR, visit the Code of Federal Regulations.)

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	none	Survey iin English	Appendix 1a. Risk Factor Assessment_French.doc		No		Paper Only
Form	none	Survey in French	Appendix 1a. Risk Factor Assessment_French.doc		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0113 Epidemic Investigation Case Records

FR Citation: 51 FR 4246

Number of Respondents: 300

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	300	300
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval	2015010-XXX_Monkeypox_Congo.docx	07/08/2015
Invitation Letter Translated	Invitation Letter - translated.docx	07/08/2015
Invitation Letter in French	Invitation letter_6 24 2015.jpg	07/08/2015

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