Information Collection

Refusal Demographics Form

IC 223708 under ICR 201609-0920-018 · OMB 0920-1137.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
PR Zika Investigation –Refusal Demographics Form Refusal Demographics Form	Form and Instruction
PR Zika Investigation –Refusal Demographics Form Vector-Control Initiatives in PR – Refusal Demographics Form_26SEpt2016.docx	Form and Instruction

IC Title:

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	PR Zika Investigation âRefusal Demographics Form	Vector-Control Initiatives in PR â Refusal Demographics Form_26SEpt2016.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0113 - Epidemic Investigation Case Records Systems Notice

FR Citation: 51 FR 42466

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	3	3
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.