Mycetoma case report form

[NCEZID] Characteristics of Cases of Priority Fungal Diseases

Documents and Forms

Document Name Document Type
Form 0920-1385 Mycetoma case report form Form
0920-1385 Mycetoma case report form Att 3h Prospective Mycetoma case report form.docx Form

Information Collection (IC) Details

IC Title:	Mycetoma case report form	Agency IC Tracking Number:	0920-1385

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	0920-1385	Mycetoma case report form	Att 3h Prospective Mycetoma 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: 25	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	125	125
Annual IC Time Burden (Hours)	63	63
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.