Information Collection

Symptom survey

IC 240024 under ICR 202002-0920-009 · OMB 0920-1316.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1316 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Symptom survey	Form
Symptom survey Att7 Symptom Survey 20200212.docx	Form

IC Title:

Symptom survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	none	Symptom survey	Att7 Symptom Survey 20200212.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Epidemiologic studies and surveillance of disease problems.

FR Citation: 57 FR 62812

Number of Respondents: 67

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	670	670
Annual IC Time Burden (Hours)	168	168
Annual IC Cost Burden (Dollars)	4,087	4,087

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.