Information Collection

State Epidemiologists

IC 7104 under ICR 201012-0920-005 · OMB 0920-0636.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0636 can be found here:

Documents and Forms

Document Name Document Type
Form 1 State Epidemiologists Form
1 Epi X Customer Survey Attachment 3 Epi X survey.docx Form
2 Immunization and Respiratory Diseases Attachment 4 Survey Questions. A docx.docx Form
3 Environmental Health Attachment 5 questions NCHE_ATSDR mtw 17 Sept. A docx.docx Form
4 Arborviral Diseases Attachment 6 Survey Questions_Arboviral Diseases .doc Form
5 Global Migration and Quarantine Attachment 7 DGMQ Questions mtw 17 Sept. A docx.docx Form
6 Rabies Attachment 8 Rabies.docx Form
7 Health Quality Promotion Attachment 9 Div Hty Quality Questions.docx Form
Attachment 10 webpage privacy policy.docx Attachment 10 webpage privacy policy IC Document
Attachment 11 Email Script.docx Attachment 11 Email Script IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Epidemiologists	Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Epi X Customer Survey	Attachment 3 Epi X survey.docx	Yes	Yes	Fillable Fileable
Form	2	Immunization and Respiratory Diseases	Attachment 4 Survey Questions. A docx.docx	Yes	Yes	Fillable Fileable
Form	3	Environmental Health	Attachment 5 questions NCHE_ATSDR mtw 17 Sept. A docx.docx	Yes	Yes	Fillable Fileable
Form	4	Arborviral Diseases	Attachment 6 Survey Questions_Arboviral Diseases .doc	Yes	Yes	Fillable Fileable
Form	5	Global Migration and Quarantine	Attachment 7 DGMQ Questions mtw 17 Sept. A docx.docx	Yes	Yes	Fillable Fileable
Form	6	Rabies	Attachment 8 Rabies.docx	Yes	Yes	Fillable Fileable
Form	7	Health Quality Promotion	Attachment 9 Div Hty Quality Questions.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,200	4,200	1,000
Annual IC Time Burden (Hours)	5,200	5,033	167
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 10 webpage privacy policy	Attachment 10 webpage privacy policy.docx	11/15/2010
Attachment 11 Email Script	Attachment 11 Email Script.docx	11/15/2010

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