(Passenger) 72-hour Food/Activity History Template (AGE cases)

Maritime Illness Database and Reporting System (MIDRS)

Documents and Forms

Document Name Document Type
Form 0920-1260 (Passenger) 72-hour Food/Activity History Template (AGE cases) Form and Instruction
0920-1260 72-hour Food/Activity History Template (AGE cases) Att5c 72-hrFoodActivityHistoryForm 20220125.docx Form and Instruction
0920-1260 72-hour Food/Activity History Template (AGE cases) Att5c 72-hrFoodActivityHistoryForm 20220125.docx Form and Instruction

Information Collection (IC) Details

IC Title:	(Passenger) 72-hour Food/Activity History Template (AGE cases)	Agency IC Tracking Number:	0920-1260

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1260	72-hour Food/Activity History Template (AGE cases)	Att5c 72-hrFoodActivityHistoryForm 20220125.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 83,850	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	83,850	66,600	17,250
Annual IC Time Burden (Hours)	13,975	11,100	2,875
Annual IC Cost Burden (Dollars)	0	0	0

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.