Information Collection

Symptom survey

IC 240024 under ICR 202307-0920-001 · OMB 0920-1316.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1316 can be found here:

Documents and Forms

Document Name Document Type
Symptom survey Form
Symptom survey Form
Symptom survey Att7 Symptom Survey 20200212.docx Form
Symptom survey Att7 Symptom Survey 20200212.docx Form
0920-1316 Symptom Survey - Revised 10JUL2023 0929-1316 Change Request Att7 Symptom Survey 06212023 FINAL.docx Form
0920-1316 Symptom Survey - Revised 10JUL2023 0929-1316 Change Request Att7 Symptom Survey 06212023 FINAL.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Symptom 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	Symptom survey	Att7 Symptom Survey 20200212.docx		Yes	Yes	Fillable Fileable
Form	0920-1316	Symptom Survey - Revised 10JUL2023	0929-1316 Change Request Att7 Symptom Survey 06212023 FINAL.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: Epidemiologic studies and surveillance of disease problems.	FR Citation: 57 FR 62812

Number of Respondents: 67	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Previously Approved
Annual Number of Responses for this IC	670	670
Annual IC Time Burden (Hours)	168	168
Annual IC Cost Burden (Dollars)	4,087	4,087

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.