Information Collection

Gas_il 2015

IC 218858 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⚠️ Notice: This information collection may be referencing outdated material.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
GAS_IL 2015	Form
GAS_IL Medical Record Abstraction Appendix 1. GAS Medical Record Abstraction.docx	Form
GAS_IL Employee Questionnaire Appendix 2. GAS Employee Questionnaire.docx	Form and Instruction
Letter of Invitation.pdf Letter of Invitation GAS_IL 2015	IC Document
2016003-XXX GAS_IL.docx GAS_IL 2015 GenIC Request	IC Document
0920-1011 GenIC Request 2016003-XXX GAS_IL.msg GAS_IL 2015 Burden Memo Email	IC Document

IC Title:

GAS_IL 2015

Agency IC Tracking Number:

0920-1011-16DK

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	NA	GAS_IL Medical Record Abstraction	Appendix 1. GAS Medical Record Abstraction.docx	NA	No		Paper Only
Form and Instruction	NA	GAS_IL Employee Questionnaire	Appendix 2. GAS Employee Questionnaire.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemic Investigation Case Records 09-20-0113

FR Citation: 51 FR 42466

Number of Respondents: 204

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	117	117
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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