Information Collection

Att D-4_Acute Flaccid Myelitis

IC 219461 under ICR 201901-0920-013 · OMB 0920-0009.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0009 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0009 Att D-4_Acute Flaccid Myelitis	Form and Instruction
0920-0009 AFM: Patient Summary Form 2019 update AFM-patient-summary-form-update abridged 7.27.2017_edits_20180122_clean.docx	Form and Instruction

IC Title:

Att D-4_Acute Flaccid Myelitis

Agency IC Tracking Number:

17AXX

Is this a Common Form? No

IC Status: Modified

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	0920-0009	AFM: Patient Summary Form 2019 update	AFM-patient-summary-form-update abridged 7.27.2017_edits_20180122_clean.docx	na	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	100	0	100
Annual IC Time Burden (Hours)	50	17	33
Annual IC Cost Burden (Dollars)	0	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.