Information Collection

Pa Ntm

IC 217651 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⚠️ Notice: This information collection may be referencing outdated material.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
PA NTM	Form
Interview Questions Appendix 1_Healthcare staff interview_PA NTM.docx	Form
Records Abstraction Information Appendix 2_Abstraction form - PA NTM.docx	Form
2015011-XXX_PA_NTM.docx EEI Request for Approval	IC Document
MAC EpiAid invitation PA 7-23-15.doc Letter of Invitation	IC Document

IC Title:

PA NTM

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR Public Health Service Act (To search for a specific CFR, visit the Code of Federal Regulations.)

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	Records Abstraction Information	Appendix 2_Abstraction form - PA NTM.docx		No		Paper Only
Form	none	Interview Questions	Appendix 1_Healthcare staff interview_PA NTM.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0113 Epidemic Investigation Case Records

FR Citation: 51 FR 42466

Number of Respondents: 10

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	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
EEI Request for Approval	2015011-XXX_PA_NTM.docx	07/26/2015
Letter of Invitation	MAC EpiAid invitation PA 7-23-15.doc	07/26/2015

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