Information Collection

Att H_42CFR71.21(a )_ Maritime Conveyance Illness or Death Investigation Form

IC 6646 under ICR 201509-0920-005 · OMB 0920-0134.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0134 can be found here:

Documents and Forms

Document Name Document Type
Form 42CFR 71.21(a) Att H_42CFR71.21(a )_ Maritime Conveyance Illness or Death Investigation Form Form
42CFR 71.21(a) Maritime Conveyance Illness or Death Investigation Form Att H_42 CFR 71.21(a) Maritime Conveyance Illness or Death Investiga.pdf Form
Cumulative Influenza/Influenza-Like Illness (ILI) Form Att I_42 CFR 71.21(a) Maritime Conveyance Cumulative ILI Form.pdf Form
Att G_Instructions for the Maritime Conveyance ....Form.pdf Att G_Instructions for the Maritime Conveyance Illness or Death Investigation Form IC Document
Att G_Guidance for Permission to Import an Inadequately Immunized Dog.docx Att G_Guidance for Permission IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att H_42CFR71.21(a )_ Maritime Conveyance Illness or Death Investigation Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR Subpart C (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	42CFR 71.21(a)	Maritime Conveyance Illness or Death Investigation Form	Att H_42 CFR 71.21(a) Maritime Conveyance Illness or Death Investiga.pdf		Yes	Yes	Fillable Fileable
Form	None	Cumulative Influenza/Influenza-Like Illness (ILI) Form	Att I_42 CFR 71.21(a) Maritime Conveyance Cumulative ILI Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Quarantine and Traveler-Related Activities, Including Records for Tracing, Investigation and Notification under 42 CFR Parts 70 and 71	FR Citation: 72 FR 70867

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att G_Instructions for the Maritime Conveyance Illness or Death Investigation Form	Att G_Instructions for the Maritime Conveyance ....Form.pdf	10/29/2015
Att G_Guidance for Permission	Att G_Guidance for Permission to Import an Inadequately Immunized Dog.docx	04/29/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.