Information Collection

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

IC 252607 under ICR 202204-0920-002 · OMB 0920-1260.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1260 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

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.