Information Collection

Maritime Conveyance Illness or Death Investigation Form (Section 5)

IC 234019 under ICR 202412-0920-009 · OMB 0920-0134.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0134 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-25CC Maritime Conveyance Illness or Death Investigation Form (Section 5) Form
0920-25CC Maritime Conveyance Illness or Death Investigation Form Attachment D - 0920-0134_Maritime Conveyance Illness or Death Investigation Form_Clean.docx Form
0920-0134 Change Request-Maritime Conveyance Illness or Death Investigation Form_12.12.2024.docx Change Request Memo IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Maritime Conveyance Illness or Death Investigation Form (Section 5)	Agency IC Tracking Number:	0920-25CC

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 71

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-25CC	Maritime Conveyance Illness or Death Investigation Form Section 5	Attachment D - 0920-0134_Maritime Conveyance Illness or Death Investigation Form_Clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Quarantine- and Traveler-Related Activities, Including Records for Contact Tracing Investigation	FR Citation: 72 FR 7086

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	100	0	100
Annual IC Time Burden (Hours)	8	0	8
Annual IC Cost Burden (Dollars)	0	-117	117

Documents for IC

Title	Document	Date Uploaded
Change Request Memo	0920-0134 Change Request-Maritime Conveyance Illness or Death Investigation Form_12.12.2024.docx	12/17/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.