International Maritime Conveyance Illness or Death Investigation Form

Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

Documents and Forms

Document Name Document Type
International Maritime Conveyance Illness or Death Investigation Form Form and Instruction
Maritime Conveyance Illness or Death Investigation Form Maritime Conveyance Illness or Death Investigation Form 0821_0134 (002).pdf Form and Instruction
Attachment B 71 21a Other illness reports MIDRS screenshot.pdf Attachment B 71 21a Other illness reports MIDRS screenshot IC Document

Information Collection (IC) Details

IC Title:	International Maritime Conveyance Illness or Death Investigation Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Maritime Conveyance Illness or Death Investigation Form 0821_0134	Maritime Conveyance Illness or Death Investigation Form 0821_0134 (002).pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Quarantine and Traveler Related Activities, including Records for Contact Tracing Investigation and Notification	FR Citation: 72 FR 70867

Number of Respondents: 750	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	750	-1,123	1,873
Annual IC Time Burden (Hours)	63	-93	156
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment B 71 21a Other illness reports MIDRS screenshot	Attachment B 71 21a Other illness reports MIDRS screenshot.pdf	03/29/2013

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