Information Collection

71.21 (c) Recordkeeping - medical records (72-hour food/activity history)

IC 235079 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
71.21 (c) Recordkeeping - medical records (72-hour food/activity history)	Form and Instruction
Gastrointestinal Illness Surveillance System Questionnai Att5c.72-hrFood_ActivityHistoryForm.doc	Form and Instruction

IC Title:

71.21 (c) Recordkeeping - medical records (72-hour food/activity history)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	Gastrointestinal Illness Surveillance System Questionnaire	Att5c.72-hrFood_ActivityHistoryForm.doc	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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	4	4
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.