OMB control number

Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

OMB 0920-0821 · HHS/CDC.

OMB 0920-0821

Latest Forms, Documents, and Supporting Material

Document Name
Ebola Entry Screening Risk Assessment (Ill Traveler Interview) Form and Instruction
Ebola Entry Screening Risk Assessment - ARABIC Form and Instruction
Ebola Entry Screening Risk Assessment - FRENCH Form and Instruction
Ebola Entry Screening Risk Assessment - ENGLISH Form and Instruction
United States Traveler Health Declaration - ARABIC Form and Instruction
United States Traveler Health Declaration - FRENCH Form and Instruction
United States Traveler Health Declaration - ENGLISH Form and Instruction
Air Travel Illness or Death Investigation Form
Land Travel Illness or Death Investigation Form
International Maritime Conveyance Illness or Death Investigation Form Form and Instruction
0920-0821 Revision Part B 02182016.docx Supporting Statement B
0920-0821 Revision Part A 02182016.doc Supporting Statement A
Attachment G Non-research Determination.pdf Supplementary Document
Attachment B 60 Day FRN 0920-0821.pdf Supplementary Document
Attachment A3 CFR-2013-title42-vol1-part71.pdf Supplementary Document
Attachment A2 CFR-2013-title42-vol1-part70.pdf Supplementary Document
Attachment A1 USCODE-2009-title42-chap6A-subchapII-partG.PDF Supplementary Document
Ebola Entry Screening Risk Assessment (Ill Traveler Interview) Form and Instruction
IVR Active Monitoring Survey - ARABIC (for translation service) Other-IVR Telephone Survey Script (Limited number - English for
IVR Active Monitoring Survey - FRENCH Other-IVR Telephone Survey Script - French
IVR Active Monitoring Survey - ENGLISH Other-IVR Telephone Survey Script - English
Ebola Entry Screening Risk Assessment - ARABIC Form and Instruction
Ebola Entry Screening Risk Assessment - FRENCH Form and Instruction
Ebola Entry Screening Risk Assessment - ENGLISH Form and Instruction
United States Traveler Health Declaration - ARABIC Form and Instruction
United States Traveler Health Declaration - FRENCH Form and Instruction
United States Traveler Health Declaration - ENGLISH Form and Instruction
Air Travel Illness or Death Investigation Form
Land Travel Illness or Death Investigation Form
International Maritime Conveyance Illness or Death Investigation Form Form and Instruction

All Historical Document Collections

201601-0920-011 Approved with change	Revision of a currently approved collection	2016-03-01
201502-0920-002 Approved without change	Revision of a currently approved collection	2015-02-11
201409-0920-006 Approved with change	No material or nonsubstantive change to a currently approved collection	2014-09-08
201304-0920-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2013-04-04
201207-0920-012 Approved without change	Revision of a currently approved collection	2012-07-27
201207-0920-003 Improperly submitted and continue	Revision of a currently approved collection	2012-07-11
201103-0920-009 Improperly submitted and continue	No material or nonsubstantive change to a currently approved collection	2011-03-28
201012-0920-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2010-12-09
201007-0920-003 Withdrawn and continue	No material or nonsubstantive change to a currently approved collection	2010-07-22
200909-0920-012 Approved without change	Existing collection in use without an OMB Control Number	2009-09-17
200906-0920-004 Improperly submitted	Existing collection in use without an OMB Control Number	2009-06-11
200902-0920-003 Improperly submitted	New collection (Request for a new OMB Control Number)	2009-02-09