Symptom Diary

[NCEZID] Oropouche Virus Disease Outbreak

Documents and Forms

Document Name Document Type
Form 0920-25AU Symptom Diary Form
0920-25AU Symptom Dairy Att. 5 Symptom Diary_Revised.docx Form

Information Collection (IC) Details

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:

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 %

	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

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.