Information Collection

AGE Illness Report 24 hours before arrival (phone/email/fax)

IC 252594 under ICR 202603-0920-012 · OMB 0920-1260.

Documents and Forms

Document Name Document Type
Form 0920-1260 AGE Illness Report 24 hours before arrival (phone/email/fax) AGE Illness Report 24 hours before arrival (phone/email/fax) Form and Instruction
0920-1260 AGE Illness Report 24 hours before arrival (phone/email/ Att5a2 24-4-hr AGEIllnssRprt (phone email fax) 20220125.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	AGE Illness Report 24 hours before arrival (phone/email/fax)	Agency IC Tracking Number:	0920-26-0121

Is this a Common Form? No		IC Status: Modified

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	0920-1260	AGE Illness Report 24 hours before arrival (phone/email/fax)	Att5a2 24-4-hr AGEIllnssRprt (phone email fax) 20220125.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	900	-4,140	5,040
Annual IC Time Burden (Hours)	45	-207	252
Annual IC Cost Burden (Dollars)	0	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.

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