Information Collection

Health Questionnaire

IC 196082 under ICR 202101-0920-010 · OMB 0920-0888.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Health Questionnaire	Form
Health Questionnaire for study "Factors Influencing the Attachment 5 - Health Questionnaire_2021-2-16.docx	Form
Health Questionnaire for study "Factors Influencing the Attachment 5 - Health Questionnaire_2021-2-16.docx	Form

IC Title:

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	n/a	Health Questionnaire for study "Factors Influencing the Transmission of Influenza"	Attachment 5 - Health Questionnaire_2021-2-16.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Occupational Health Epidemiological Studies and EEOICPA Records

FR Citation: 76 FR 34706

Number of Respondents: 90

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	90	0	90
Annual IC Time Burden (Hours)	8	0	8
Annual IC Cost Burden (Dollars)	109	109	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.