OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

2014013-XXX_Resp Illness UAC_Multi

IC 212348 under ICR 201511-0920-002 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Document Name Document Type
Appendix 1 - Case Investigation Form.docx Other-WORD
Appendix 2 - Medical Record Form.docx Other-WORD
FW CDC Epi Aid request received from ORR.msg CDC Epi Aid Request IC Document
0920-1011 URGENT GenIC Request Resp Illness UAC_Multi.msg 0920-1011 URGENT Request Email IC Document
2014013-XXX_Resp Illness_UAC shelters.docx 2-14013-XXX Res Illness UAC Multi IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2014013-XXX_Resp Illness UAC_Multi	Agency IC Tracking Number:	14AOP

IC Status: Unchanged

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
Other-WORD			Appendix 1 - Case Investigation Form.docx		No		Fillable Printable
Other-WORD			Appendix 2 - Medical Record Form.docx		No		Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 550	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	550	0	0	0	0	550
Annual IC Time Burden (Hours)	275	0	0	0	0	275
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CDC Epi Aid Request	FW CDC Epi Aid request received from ORR.msg	07/15/2014
0920-1011 URGENT Request Email	0920-1011 URGENT GenIC Request Resp Illness UAC_Multi.msg	07/15/2014
2-14013-XXX Res Illness UAC Multi	2014013-XXX_Resp Illness_UAC shelters.docx	07/16/2014

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