CRF Symptom Screener

[NCEZID] Enhanced surveillance of respiratory illness among people experiencing homelessness in Anchorage, Alaska

Documents and Forms

Document Name Document Type
CRF Symptom Screener Form and Instruction
CRF Symptom Screener Attachment 3_CRF_symptom screener_10-12-22_final.docx Form and Instruction
CRF Symptom Screener Attachment 3_CRF_symptom screener_10-12-22_final.docx Form and Instruction
0920-1399 CRF Symptom Screener - Enrollment form, symptom screenin Attachment 3_CRF_symptom screener_10.20.23_CLEAN.docx Form and Instruction
0920-1399 CRF Symptom Screener - Enrollment form, symptom screenin Attachment 3_CRF_symptom screener_10.20.23_CLEAN.docx Form and Instruction

Information Collection (IC) Details

IC Title:	CRF Symptom Screener	Agency IC Tracking Number:	0920-22FT

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 and Instruction	n/a	CRF Symptom Screener	Attachment 3_CRF_symptom screener_10-12-22_final.docx		Yes	No	Fillable Fileable
Form and Instruction	0920-1399	CRF Symptom Screener - Enrollment form, symptom screening, and vaccination status 27OCT2023	Attachment 3_CRF_symptom screener_10.20.23_CLEAN.docx	N/A	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	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	1,000	1,000
Annual IC Time Burden (Hours)	500	500
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.