ALS DIsease Progression Survey

[ATSDR] National Amyotrophic Lateral Sclerosis (ALS) Registry

Documents and Forms

Document Name Document Type
ALS DIsease Progression Survey Form
Disease Progression Survey P_AppE2 - Disease Progression.docx Form
Disease Progression Survey P_AppE2 - Disease Progression.docx Form

Information Collection (IC) Details

IC Title:	ALS DIsease Progression Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	none	Disease Progression Survey	P_AppE2 - Disease Progression.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 Toxic or Hazardous Substances, 09-19-0001	FR Citation: 76 FR 4432

Number of Respondents: 750	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,250	2,250
Annual IC Time Burden (Hours)	188	188
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.