Information Collection

Outbreak Summary Report Form

IC 248661 under ICR 202108-0920-001 · OMB 0920-1353.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1353 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-21EE Outbreak Summary Report Form	Form
0920-21EE Att 3e_Outbreak Summary Report Att 3e_Outbreak Summary Report_5-18-2021.docx	Form
0920-21EE Att 3e_Outbreak Summary Report Att 3e_Outbreak Summary Report_5-18-2021_rev.docx	Form and Instruction

IC Title:

Outbreak Summary Report Form

Agency IC Tracking Number:

0920-21EE

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Mandatory

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	0920-21EE	Att 3e_Outbreak Summary Report	Att 3e_Outbreak Summary Report_5-18-2021_rev.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 59

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	118	118
Annual IC Time Burden (Hours)	39	39
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.