Information Collection

Blastomycosis Case Report Form

IC 266000 under ICR 202501-0920-004 · OMB 0920-1385.

Documents and Forms

Document Name Document Type
Form 0920-1385 Blastomycosis Case Report Form Form
0920-1385 Blastomycosis Case Report Form Att 3d Blastomycosis Case Report Form.docx Form
0920-1385 Blastomycosis Case Report Form Att 3d Clean_Blastomycosis Case Report Form.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Blastomycosis Case Report Form	Agency IC Tracking Number:	0920-1385

Is this a Common Form? No		IC Status: Modified

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	0920-1385	Blastomycosis Case Report Form	Att 3d Clean_Blastomycosis Case Report Form.docx		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 %

	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

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.