Information Collection

Questionnaire for Ebola-Affected Households

IC 214717 under ICR 201501-0920-021 · OMB 0920-1043.

Documents and Forms

Document Name Document Type
Questionnaire for Ebola-Affected Households Form and Instruction
Questionnaire for Ebola-affected Households Att2 Questnnre for Ebola HHs 20150118.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Questionnaire for Ebola-Affected Households	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 and Instruction	None	Questionnaire for Ebola-affected Households	Att2 Questnnre for Ebola HHs 20150118.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records
Title: 09-20-0113 Epi Invest Case Records	FR Citation: 51 FR 42466

Number of Respondents: 119	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	119	119
Annual IC Time Burden (Hours)	40	40
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.