Information Collection

Baseline and Follow-Up Questionnaire - Symptomatic

IC 222264 under ICR 201606-0920-022 · OMB 0920-1140.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1140 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Baseline and Follow-Up Questionnaire - Symptomatic	Form and Instruction
Baseline and Follow-Up Questionnaire - English 29SEP2016 Att H - Baseline and follow-up questionnaire.docx	Form and Instruction
Baseline and Follow-Up Questionnaire - Spanish 29SEP2016 Att H - Baseline and follow-up questionnaire ESP.docx	Form and Instruction

IC Title:

Baseline and Follow-Up Questionnaire - Symptomatic

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 and Instruction	NA	Baseline and Follow-Up Questionnaire - Spanish 29SEP2016	Att H - Baseline and follow-up questionnaire ESP.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Baseline and Follow-Up Questionnaire - English 29SEP2016	Att H - Baseline and follow-up questionnaire.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 - Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,600	1,600
Annual IC Time Burden (Hours)	267	267
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.