71.21 (c) 72-hour food/activity history - AGE Passenger and Crew cases

Maritime Illness Database and Reporting System (MIDRS)

⚠️ Notice: This information collection may be referencing outdated material.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) 72-hour food/activity history - AGE Passenger and Crew cases Form and Instruction
72-hr Food/Activity History Template Att5c.72-hrFood_ActivityHistoryForm.doc Form and Instruction

Information Collection (IC) Details

IC Title:	71.21 (c) 72-hour food/activity history - AGE Passenger and Crew cases	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	72-hr Food/Activity History Template	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: 5,000	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	5,000	5,000
Annual IC Time Burden (Hours)	833	833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.