Information Collection

Ebola Exposure Questionnaire for Cleaning Crew

IC 213969 under ICR 201411-0920-006 · OMB 0920-1032.

Documents and Forms

Document Name Document Type
Ebola Exposure Questionnaire for Cleaning Crew Form
Ebola Exposure Questionnaire for Cleaning Crew Attachment D ExposureQuestionnaire_CleaningCrew.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Ebola Exposure Questionnaire for Cleaning Crew	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form	None	Ebola Exposure Questionnaire for Cleaning Crew	Attachment D ExposureQuestionnaire_CleaningCrew.docx	None	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	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.