State and Local HD Staff Form 1 part B

[NCEZID] Adverse Health Outcomes Associated with Medical Tourism Surveillance System

Documents and Forms

Document Name Document Type
State and Local HD Staff Form 1 part B Form and Instruction
Form 1 Medical Tourism Case Intake Form Att. C - Form 1 Medical Tourism Case Intake Form_0625final_v2.docx Form and Instruction

Information Collection (IC) Details

IC Title:	State and Local HD Staff Form 1 part B	Agency IC Tracking Number:	0920-24HD

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 and Instruction	n/a	Form 1 Medical Tourism Case Intake Form	Att. C - Form 1 Medical Tourism Case Intake Form_0625final_v2.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	750	750
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.