Site Baseline Survey

[NCEZID] School-Based Active Surveillance (SBAS) of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren: Phase-2 of the National Roll-Out

Documents and Forms

Document Name Document Type
Form 0920-22HN Site Baseline Survey Form and Instruction
0920-22HN Attachment C_SBAS_Site Baseline Survey Attachment C_SBAS_Site Baseline Survey.docx Form and Instruction
0920-22HN Attachment C_SBAS_Site Baseline Survey Attachment C_SBAS_Site Baseline Survey.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Site Baseline Survey	Agency IC Tracking Number:	0920-22HN

Is this a Common Form? Yes		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	0920-22HN	Attachment C_SBAS_Site Baseline Survey	Attachment C_SBAS_Site Baseline Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	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
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	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.