Case Questionnaire - Dog Owner

Canine Leptospirosis Surveillance in Puerto Rico

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1170 can be found here:

Documents and Forms

Document Name Document Type
Case Questionnaire - Dog Owner Form
Case Questionnaire - Dog Owner Att E--Case_Questionnaire_2016_9_22 lepto PR.doc Form
Case Questionnaire for Dog Owner - Spanish Att E--Case_Questionnaire_2016_12_19_Spanish.doc Form

Information Collection (IC) Details

IC Title:	Case Questionnaire - Dog Owner	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	none	Case Questionnaire - Dog Owner	Att E--Case_Questionnaire_2016_9_22 lepto PR.doc		No		Paper Only
Form	none	Case Questionnaire for Dog Owner - Spanish	Att E--Case_Questionnaire_2016_12_19_Spanish.doc		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 624	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	624	624
Annual IC Time Burden (Hours)	52	52
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.