Information Collection

57.115_cus_blank

IC 222891 under ICR 202010-0920-016 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form CDC 57.115 57.115_CUS_BLANK Form
CDC 57.115 Custom Event COVID-19_FieldAddition_57.115_CUS_BLANK.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.115_CUS_BLANK	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	CDC 57.115	Custom Event	COVID-19_FieldAddition_57.115_CUS_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	54,600	0	54,600
Annual IC Time Burden (Hours)	31,850	-910	32,760
Annual IC Cost Burden (Dollars)	1,263,171	0	1,263,171

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.