Information Collection

Adult Symptom Diary

IC 251055 under ICR 202212-0923-001 · OMB 0923-0064.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-22BJ Adult 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:

Adult Symptom Diary

Agency IC Tracking Number:

0923-22BJ

Is this a Common Form? No

IC Status: Unchanged

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: 1,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,400	1,400
Annual IC Time Burden (Hours)	5,600	5,600
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.