Information Collection

Att H_42CFR71.21(a )_ Maritime Conveyance Illness or Death Investigation Form (Sections 1-4)

IC 6646 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⚠️ Notice: This information collection may be referencing outdated material.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 42CFR 71.21(a) Att H_42CFR71.21(a )_ Maritime Conveyance Illness or Death Investigation Form (Sections 1-4)	Form and Instruction
42CFR 71.21(a) Maritime Conveyance illness or Death Investigation Form Attachment D Maritime Conveyance Illness or Death Investigation Form.pdf	Form and Instruction
42CFR 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:

Att H_42CFR71.21(a )_ Maritime Conveyance Illness or Death Investigation Form (Sections 1-4)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR Subpart C (To search for a specific CFR, visit the Code of Federal Regulations.)

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	42CFR 71.21(a)	Maritime Conveyance illness or Death Investigation Form	Attachment D Maritime Conveyance Illness or Death Investigation Form.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Quarantine and Traveler-Related Activities, Including Records for Tracing, Investigation and Notification under 42 CFR Parts 70 and 71

FR Citation: 72 FR 70867

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	1,635	1,635

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.