Information Collection

Record of Sickness or Death

IC 253392 under ICR 202601-0920-009 · OMB 0920-1383.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Record of Sickness or Death.docx	Other-Header and Burden Statement
Record of Sickness or Death.docx	Other-Header and Burden Statement

IC Title:

Agency IC Tracking Number:

0920-22BY

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

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
Other-Header and Burden Statement					No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Quarantine-and-Traveler-Related Activities

FR Citation: 83 FR 6591

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	25	25
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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