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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.