Information Collection

EVD Person Under Investigation (PUI) Form

IC 217543 under ICR 201507-0920-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
EVD Person Under Investigation (PUI) Form	Form and Instruction
Person Under Investigation (PUI) for Ebola Form - United Att3 EVD Person Under Investigation Form 20150123.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

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 and Instruction	NA	Person Under Investigation (PUI) for Ebola Form - United States	Att3 EVD Person Under Investigation Form 20150123.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 âEpidemiologic Studies and Surveillance of Disease Problems

FR Citation: 51 FR 42466

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	50	50
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.