UAB Questionnaire

Information Collection on Soil-transmitted Helminth Infections in Alabama and Mississippi

Documents and Forms

Document Name Document Type
UAB Questionnaire Form
UAB Questionnaire Attachment C. UAB Questionnaire_FINAL_OMB edits_06202019 clean (OMB)_AS 09232019_CLEAN.docx Form
Part of C.consent.clean.190211 IRB Approved.pdf Consent IC Document

Information Collection (IC) Details

IC Title:	UAB Questionnaire	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	UAB Questionnaire	Attachment C. UAB Questionnaire_FINAL_OMB edits_06202019 clean (OMB)_AS 09232019_CLEAN.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	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	600	600
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	725	725

Documents for IC

Title	Document	Date Uploaded
Consent	Part of C.consent.clean.190211 IRB Approved.pdf	10/07/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.