Information Collection

Household Surveillance patients Form 6a Medical History

IC 218291 under ICR 201509-0925-002 · OMB 0925-0737.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 23 Household Surveillance patients Form 6a Medical History	Form
23 Attachment 8 Form 6a Medical History Attachment 8 -Form6a Medical History.pdf	Form

IC Title:

Agency IC Tracking Number:

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	23	Attachment 8 Form 6a Medical History	Attachment 8 -Form6a Medical History.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	83	83
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.