OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

2014010-XXX Ebola_Guinea

IC 212127 under ICR 201511-0920-002 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1011 2014010-XXX Ebola_Guinea	Form and Instruction
0920-1011 Appendix 1- Case Investigation Form Appendix 1- Case Investigation Form.pdf	Form and Instruction
0920-1011 Appendix 2- Contact Tracing Form Appendix 2- Contact Tracing Form.pdf	Form
2014-010-XXX_Ebola_Guinea.docx 2014-010-XXX_Ebola_Guinea	IC Document
MoH invitation Guinea.pdf MoH invitation Guinea	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

2014010-XXX Ebola_Guinea

Agency IC Tracking Number:

0920-1011 14AMN

IC Status: Unchanged

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	0920-1011	Appendix 1- Case Investigation Form	Appendix 1- Case Investigation Form.pdf		No		Fillable Printable
Form	0920-1011	Appendix 2- Contact Tracing Form	Appendix 2- Contact Tracing Form.pdf		No		Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,600

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 New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	2,600	0	0	0	0	2,600
Annual IC Time Burden (Hours)	351	0	0	0	0	351
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2014-010-XXX_Ebola_Guinea	2014-010-XXX_Ebola_Guinea.docx	06/27/2014
MoH invitation Guinea	MoH invitation Guinea.pdf	06/27/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.