Land Travel Illness or Death Investigation Form

Foreign Quarantine Regulations (42CFR71)

⚠️ Notice: This information collection may be referencing outdated material.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
Land Travel Illness or Death Investigation Form Form
Land Travel Illness or Death Investigation Form Attachment F - Land Travel Illness or Death Investigation Form-3.23.pdf Form
Land Travel Illness or Death Investigation Form Attachment F - Land Travel Illness or Death Investigation Form-3.23.pdf Form

Information Collection (IC) Details

IC Title:	Land Travel Illness or Death Investigation Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 70 sec 4 42 CFR 71 sec 21

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Land Travel Illness or Death Investigation Form	Attachment F - Land Travel Illness or Death Investigation Form-3.23.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: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,000	2,900	100
Annual IC Time Burden (Hours)	750	742	8
Annual IC Cost Burden (Dollars)	5,842	5,647	195

Documents for IC

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.