Information Collection

Baseline and Follow-Up Questionnaire - Asymptomatic

IC 222265 under ICR 201707-0920-005 · OMB 0920-1140.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Baseline and Follow-Up Questionnaire - Asymptomatic	Form and Instruction
Baseline and Follow-Up Questionnaire - English 29SEP2016 Att H - Baseline and follow-up questionnaire.docx	Form and Instruction
Baseline and Follow-Up Questionnaire - Spanish 29SEP2016 Att H - Baseline and follow-up questionnaire ESP.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	Baseline and Follow-Up Questionnaire - English 29SEP2016	Att H - Baseline and follow-up questionnaire.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Baseline and Follow-Up Questionnaire - Spanish 29SEP2016	Att H - Baseline and follow-up questionnaire ESP.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 - Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-600	600
Annual IC Time Burden (Hours)	-100	100
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.