Information Collection

Child 7-17 Symptom Diary

IC 251059 under ICR 202112-0923-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-22BJ Child 7-17 Symptom Diary	Form and Instruction
0923-22BJ Symptom Diary P_ApndxE_SymptmDiary_11092021.docx	Form and Instruction
0923-22BJ Symptom Diary P_ApndxE_SymptmDiary_11092021.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0923-22BJ

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	0923-22BJ	Symptom Diary	P_ApndxE_SymptmDiary_11092021.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Hazardous or Toxic Substances (retrievable by name or SSN)

FR Citation: 76 FR 4431

Number of Respondents: 139

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	139	139
Annual IC Time Burden (Hours)	556	556
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.