Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone

Surveillance Data Collections for Ebola Virus Disease in West Africa

Documents and Forms

Document Name Document Type
Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone Form and Instruction
Health Care Worker EVD Exposure Risk Reporting Form - Si Att30 HCW.EVD.expriskreport_SierraLeone.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone	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 and Instruction	None	Health Care Worker EVD Exposure Risk Reporting Form - Sierra Leone	Att30 HCW.EVD.expriskreport_SierraLeone.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 73	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 20 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	73	73
Annual IC Time Burden (Hours)	37	37
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.