Information Collection

NARMS SIRI Questionnaire Module 1

IC 273883 under ICR 202501-0920-007 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form 5 NARMS SIRI Questionnaire Module 1	Form and Instruction
Form Form 5 NARMS SIRI Module 1 NARMS SIRI Questionnaire Module 1	Form and Instruction
Form 5 NARMS SIRI Module 1 Form 5 - NARMS SIRI Module 1_Final_rev.docx	Form and Instruction
Form 5 NARMS SIRI Module 1 Form 5 - NARMS SIRI Module 1_Final_rev.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-24EE

Is this a Common Form? No

IC Status: New

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 and Instruction	Form 5				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 51 FR 42449

Number of Respondents: 305

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 70 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	305	305
Annual IC Time Burden (Hours)	76	76
Annual IC Cost Burden (Dollars)	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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