Information Collection

Maritime Conveyance Illness or Death Investigation Form (Section 5)

IC 234019 under ICR 202111-0920-006 · OMB 0920-0134.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0134 can be found here:

Documents and Forms

Document Name Document Type
Form 42 CFR 71.21(a) Maritime Conveyance Illness or Death Investigation Form (Section 5) Form and Instruction
42 CFR 71.21(a) Maritime Conveyance Illness or Death Investigation Form Attachment D Maritime Conveyance Illness or Death Investigation Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Maritime Conveyance Illness or Death Investigation Form (Section 5)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 71

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	42 CFR 71.21(a)	Maritime Conveyance Illness or Death Investigation Form (Section 5)	Attachment D Maritime Conveyance Illness or Death Investigation Form.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Quarantine- and Traveler-Related Activities, Including Records for Contact Tracing Investigation	FR Citation: 72 FR 7086

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	117	117

Documents for IC

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