Information Collection

Land Travel Illness or Death Investigation Form

IC 234020 under ICR 202603-0920-008 · OMB 0920-0134.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Land Travel Illness or Death Investigation Form Land Travel Illness or Death Investigation Form	Form and Instruction
Land Travel Illness or Death Investigation Form Attachment C - Land Travel Illness or Death Investigation Form_3_23 2025rev CLEAN.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-26-0139

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 70 sec 4 42 CFR 71 sec 21

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	none				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Quarantine- and Traveler-Related Activities, Including Records for Contact Tracing Investigation

FR Citation: 72 FR 7086

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	200	-2,800	3,000
Annual IC Time Burden (Hours)	50	-700	750
Annual IC Cost Burden (Dollars)	0	-5,842	5,842

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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