Voluntary Survey Modules

National Amyotrophic Lateral Sclerosis (ALS) Registry

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0041 can be found here:

Documents and Forms

Document Name Document Type
Voluntary Survey Modules Form
Voluntary ALS Survey Modules Attach_6-Approved Surveys (screenshots)-with OMB box.docx Form
Attach_6A-Scoring ALSFRS final.docx ALS Functional Rating Scale IC Document

Information Collection (IC) Details

IC Title:	Voluntary Survey Modules	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	none	Voluntary ALS Survey Modules	Attach_6-Approved Surveys (screenshots)-with OMB box.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 76 FR 4432

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

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	750	-11,250	12,000
Annual IC Time Burden (Hours)	1,000	0	1,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
ALS Functional Rating Scale	Attach_6A-Scoring ALSFRS final.docx	06/22/2016

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