Information Collection

Case Report Form for Coccidioidomycosis

IC 216654 under ICR 201505-0920-006 · OMB 0920-1087.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Case Report Form for Coccidioidomycosis	Form
Case Report for Coccidioidomycosis Attachment 4 CRF for cocci enhanced surveillance 4.15.15.docx	Form

IC Title:

Agency IC Tracking Number:

15UR

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?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Case Report for Coccidioidomycosis	Attachment 4 CRF for cocci enhanced surveillance 4.15.15.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 145

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	145	145
Annual IC Time Burden (Hours)	48	48
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.