Information Collection

Passenger Locator Form (Domestic)

IC 219176 under ICR 201512-0920-001 · OMB 0920-0488.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0488 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Passenger Locator Form (Domestic)	Form
Passenger Locator Attachment 3 Passenger Locator Form.docx	Form

IC Title:

Passenger Locator Form (Domestic)

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	none	Passenger Locator	Attachment 3 Passenger Locator Form.docx		No		Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: 09-20-0171 Quarantine and Traveler Related Activities, Inlcuding Records for Contact Tracing Investingations

FR Citation: 72 FR 7086

Number of Respondents: 800

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	800	800
Annual IC Time Burden (Hours)	67	67
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.