Information Collection

Maritime Conveyance Illness or Death Investigation Form (Section 5)

IC 234019 under ICR 202111-0920-018 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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
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

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:

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	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 %

table that charts list of burden
	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

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.