Information Collection

Record of Sickness or Death

IC 253392 under ICR 202406-0920-001 · OMB 0920-1383.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1383 can be found here:

Documents and Forms

Document Name Document Type
Record of Sickness or Death.docx Other-Header and Burden Statement
Record of Sickness or Death.docx Other-Header and Burden Statement

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Record of Sickness or Death	Agency IC Tracking Number:	0920-22BY

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Header and Burden Statement			Record of Sickness or Death.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Quarantine-and-Traveler-Related Activities	FR Citation: 83 FR 6591

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	50	7	43
Annual IC Time Burden (Hours)	25	-18	43
Annual IC Cost Burden (Dollars)	0	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.