Information Collection

Covid-19 Contact Tracing Reporting Form

IC 244227 under ICR 202010-1670-001 · OMB 1670-0044.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DHS Form XXX (10/2 COVID-19 CONTACT TRACING REPORTING FORM COVID-19 CONTACT TRACING REPORTING FORM	Form and Instruction
DHS Form XXX (10/2 COVID-19 CONTACT TRACING REPORTING FORM DHS Form XXX_1670-NEW_COVID-19 Contact Tracing Reporting Form_3_FORM-v1.pdf	Form and Instruction

IC Title:

COVID-19 CONTACT TRACING REPORTING FORM

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 and Instruction	DHS Form XXX (10/20)				Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: PIA-069 DHS Surveys, Interviews, and Focus Groups

FR Citation: 73 FR 71659

Number of Respondents: 166

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	166	166
Annual IC Time Burden (Hours)	111	111
Annual IC Cost Burden (Dollars)	0	0

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.

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