Outreach Reporting Form for Chapters and Districts

[ATSDR] National Amyotrophic Lateral Sclerosis (ALS) Registry

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0041 can be found here:

Documents and Forms

Document Name Document Type
Outreach Reporting Form for Chapters and Districts Form
Chapter/District Outreach Reporting Att6A Chapter-District Outreach Reprt.xlsx Form
Chapter/District Outreach Reporting Att6A Chapter-District Outreach Reprt.xlsx Form

Information Collection (IC) Details

IC Title:	Outreach Reporting Form for Chapters and Districts	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	Chapter/District Outreach Reporting	Att6A Chapter-District Outreach Reprt.xlsx		Yes	No	Paper Only

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: 135	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,620	1,620
Annual IC Time Burden (Hours)	135	135
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.