State/Local General Outcome Reporting (Air)

Contact Investigation Outcome Reporting Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0900 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0900 State/Local General Outcome Reporting (Air) Form
0920-0900 General Contact Investigation Outcome Reporting Form - A General Contact Investigation Outcome Reporting Form_Air_rev10.2021.pdf Form
0920-0900 General Contact Investigation Outcome Reporting Form - A General Contact Investigation Outcome Reporting Form_Air_rev10.2021.pdf Form
General Contact Investigation Outcome Reporting Form_Air_redline.docx General Air Contact Investigation Outcome Reporting Form IC Document
General Contact Investigation Outcome Reporting Form_Air_redline.docx General Air Contact Investigation Outcome Reporting Form IC Document

Information Collection (IC) Details

IC Title:	State/Local General Outcome Reporting (Air)	Agency IC Tracking Number:	0920-0900-22AK

Is this a Common Form? No		IC Status: Modified

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	0920-0900	General Contact Investigation Outcome Reporting Form - Air	General Contact Investigation Outcome Reporting Form_Air_rev10.2021.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 0920-0171 Quarantine and Traveler Related Activities, Including Records for Cpmtact Tracing Investigation and Notification under 42 CFR Parts 70 and 71	FR Citation: 72 FR 70867

Number of Respondents: 16,672	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	16,672	16,672
Annual IC Time Burden (Hours)	1,389	1,389
Annual IC Cost Burden (Dollars)	51,850	51,850

Documents for IC

Title	Document	Date Uploaded
General Air Contact Investigation Outcome Reporting Form	General Contact Investigation Outcome Reporting Form_Air_redline.docx	11/01/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.