COVID-19 Registrtion Form

COVID-19 by PCR Requisition Form

Documents and Forms

Document Name Document Type
COVID-19 Testing Center Requisition Form 2020.04.23.docx Other-Registration Form

Information Collection (IC) Details

IC Title:	COVID-19 Registrtion Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Registration Form			COVID-19 Testing Center Requisition Form 2020.04.23.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200,000	200,000
Annual IC Time Burden (Hours)	13,333	13,333
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.