General Public - Household Member Symptom Diary

SARS-CoV-2 Epidemiologic Data Collections

Documents and Forms

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

Information Collection (IC) Details

IC Title:	General Public - Household Member Symptom Diary	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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 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 %

	Approved	Previously Approved
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

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.