Covid-19 Contact Tracing Reporting Form

COVID-19 Tracing Reporting Form

Documents and Forms

Document Name Document Type
Form DHS Form XXX (10/2 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

Information Collection (IC) Details

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:

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)	COVID-19 CONTACT TRACING REPORTING FORM	DHS Form XXX_1670-NEW_COVID-19 Contact Tracing Reporting Form_3_FORM-v1.pdf		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 %

	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

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.