Information Collection

71.21 (c) Documentation of 3-day pre-embarkation AGE illness assessment for all crew members

IC 235075 under ICR 201812-0920-009 · OMB 0920-1260.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1260 can be found here:

Documents and Forms

Document Name Document Type
71.21 (c) Documentation of 3-day pre-embarkation AGE illness assessment for all crew members Form and Instruction
Documentation of 3-day pre-embarkation AGE illness asses Att5e.Documentation of 3-day pre-embarkation AGE illness assessment.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	71.21 (c) Documentation of 3-day pre-embarkation AGE illness assessment for all crew members	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Documentation of 3-day pre-embarkation AGE illness assessment	Att5e.Documentation of 3-day pre-embarkation AGE illness assessment.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,250	1,250
Annual IC Time Burden (Hours)	63	63
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.