Information Collection

General Public - Household Member Symptom Diary

IC 241631 under ICR 202004-0920-016 · OMB 0920-1297.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1297 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
General Public - Household Member Symptom Diary	Form and Instruction
Household Member Symptom Diary 6. HH Transmission_Household member symptom diary_instrument_OMB_23Apr2020.docx	Form and Instruction

IC Title:

General Public - Household Member Symptom Diary

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 and Instruction	NA	Household Member Symptom Diary	6. HH Transmission_Household member symptom diary_instrument_OMB_23Apr2020.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 92812

Number of Respondents: 200

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	200	200
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

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.