Information Collection

Att H_42CFR71.21(a )_ Maritime Conveyance Illness or Death Investigation Form (Sections 1-4)

IC 6646 under ICR 201811-0920-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 (Sections 1-4) Form and Instruction
42CFR 71.21(a) Maritime Conveyance illness or Death Investigation Form Attachment D Maritime Conveyance Illness or Death Investigation Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att H_42CFR71.21(a )_ Maritime Conveyance Illness or Death Investigation Form (Sections 1-4)	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 and Instruction	42CFR 71.21(a)	Maritime Conveyance illness or Death Investigation Form	Attachment D Maritime Conveyance Illness or Death Investigation Form.pdf	NA	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: 500	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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	-1,500	2,000
Annual IC Time Burden (Hours)	42	-25	67
Annual IC Cost Burden (Dollars)	1,635	1,635	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.