Information Collection

Ebola Exposure Questionnaire for Cleaning Crew

IC 215020 under ICR 201712-0920-005 · OMB 0920-0900.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0900 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Ebola Exposure Questionnaire for Cleaning Crew	Form and Instruction
Ebola Exposure Questionnaire for Cleaninig Crew Attachment R ExposureQuestionnaire_CleaningCrew.docx	Form and Instruction

IC Title:

Ebola Exposure Questionnaire for Cleaning Crew

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	None	Ebola Exposure Questionnaire for Cleaninig Crew	Attachment R ExposureQuestionnaire_CleaningCrew.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Quarantine- and Traveler-Related Activities

FR Citation: 72 FR 7086

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	40	40
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.