ALS DIsease Progression Survey

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⚠️ Notice: This information collection may be referencing outdated material.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
ALS DIsease Progression Survey Form
Disease Progression Survey - 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:	ALS DIsease Progression Survey	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	Disease Progression Survey - 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, 09-19-0001	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	2,250	525	1,725
Annual IC Time Burden (Hours)	188	44	144
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.