General Public - Household Close-Out Form

SARS-CoV-2 Epidemiologic Data Collections

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
General Public - Household Close-Out Form Form and Instruction
Household Close-Out Form 8. HH Transmission_Household Close Out Form_Instrument_OMB_23Apr2020.docx Form and Instruction

Information Collection (IC) Details

IC Title:	General Public - Household Close-Out 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 and Instruction	NA	Household Close-Out Form	8. HH Transmission_Household Close Out Form_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: 60	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

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.