Information Collection

Male Partners - Adult Symptoms Questionnaire

IC 226478 under ICR 201703-0920-014 · OMB 0920-1190.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1190 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Male Partners - Adult Symptoms Questionnaire	Form and Instruction
ZEN Columbia - Adult Symptoms Questionnaire - Spanish Att_C5_Sintomas Adultos_Formatted_030217_CLEAN.docx	Form and Instruction
ZEN Columbia - Adult Symptoms Questionnaire - English Att B5 - Adult Symptoms_052517_CLEAN.docx	Form and Instruction

IC Title:

Male Partners - Adult Symptoms Questionnaire

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	ZEN Columbia - Adult Symptoms Questionnaire - Spanish	Att_C5_Sintomas Adultos_Formatted_030217_CLEAN.docx	NA	No		Paper Only
Form and Instruction	NA	ZEN Columbia - Adult Symptoms Questionnaire - English	Att B5 - Adult Symptoms_052517_CLEAN.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 System

FR Citation: 51 FR 42466

Number of Respondents: 625

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	4,375	4,375
Annual IC Time Burden (Hours)	729	729
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.