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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.