Neurologic Exam Form

Long-term sequela of Rocky Mountain Spotted Fever (RMSF)

Documents and Forms

Document Name Document Type
Neurologic Exam Form Form
Neurologic Exam Form 4. Neuro Exam Form.pdf Form

Information Collection (IC) Details

IC Title:	Neurologic Exam Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Neurologic Exam Form	4. Neuro Exam Form.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 42	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	28	28
Annual IC Cost Burden (Dollars)	507	507

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.