Information Collection

Histoplasmosis Case Report Form

IC 265999 under ICR 202501-0920-004 · OMB 0920-1385.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1385 Histoplasmosis Case Report Form	Form
Form 0920-1385 Histoplasmosis Case Report Form Histoplasmosis Case Report Form	Form
0920-1385 Histoplasmosis Case Report Form Att 3c Histoplasmosis Case Report Form.docx	Form
0920-1385 Histoplasmosis Case Report Form Att 3c Clean_Histoplasmosis Case Report Form.docx	Form

IC Title:

Agency IC Tracking Number:

0920-1385

Is this a Common Form? No

IC Status: Modified

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	0920-1385				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	455	205	250
Annual IC Time Burden (Hours)	280	30	250
Annual IC Cost Burden (Dollars)	0	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.

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