Information Collection

Symptom Diary

IC 271897 under ICR 202410-0920-025 · OMB 0920-1446.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1446 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-25AU Symptom Diary	Form
0920-25AU Symptom Dairy Att. 5 Symptom Diary_Revised.docx	Form

IC Title:

Symptom Diary

Agency IC Tracking Number:

0920-25AU

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-25AU	Symptom Dairy	Att. 5 Symptom Diary_Revised.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.