Study Intake Form

Persistence of Ebola Virus in Body Fluids of Ebola Virus Disease Survivors in Sierra Leone

Documents and Forms

Document Name Document Type
Study Intake Form Form
Study Intake Form Att1_IntakeForm.xlsx Form

Information Collection (IC) Details

IC Title:	Study Intake Form	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?	Can Be Submitted Electronically?	Electronic Capability
Form	None	Study Intake Form	Att1_IntakeForm.xlsx	None	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	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	550	550
Annual IC Time Burden (Hours)	183	183
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.