Survivor Questionnaire - Pilot

Persistence of Ebola Virus in Body Fluids of Ebola Virus Disease Survivors in Sierra Leone

Documents and Forms

Document Name Document Type
Survivor Questionnaire - Pilot Form
Survivor Questionnaire (Initial Study Visit and Follow-u Att5_SurvivorQuestionnaire 20150518 clean.docx Form

Information Collection (IC) Details

IC Title:	Survivor Questionnaire - Pilot	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	NA	Survivor Questionnaire (Initial Study Visit and Follow-up) - Male/Female Pilot	Att5_SurvivorQuestionnaire 20150518 clean.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.