0920-1011 Specimen Manifest Form

Form Approved

OMB # 0920-1011

Exp. 01/31/2020

Specimen Manifest Form

CDC Case ID	State Case ID	Sample ID	Matrix (specimen type)	Shipping Box # or ID	Position in Shipping Box	Volume (mL) of Specimen	Collection Date of Specimen	Comments about Specimen

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1011).