Information Collection

71.21(c) Recordkeeping - medical records (Documentation of 3-day pre-embarkation AGE illness assessment for all crew members)

IC 235076 under ICR 202204-0920-002 · OMB 0920-1260.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1260 can be found here:

Documents and Forms

Document Name Document Type
71.21(c) Recordkeeping - medical records (Documentation of 3-day pre-embarkation AGE illness assessment for all crew members) Form and Instruction
Documentation of 3-day pre-embarkation AGE illness asses Att5e.Documentation of 3-day pre-embarkation AGE illness assessment.docx Form and Instruction
Documentation of 3-day pre-embarkation AGE illness asses Att5e.Documentation of 3-day pre-embarkation AGE illness assessment.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	71.21(c) Recordkeeping - medical records (Documentation of 3-day pre-embarkation AGE illness assessment for all crew members)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Mandatory

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	NA	Documentation of 3-day pre-embarkation AGE illness assessment	Att5e.Documentation of 3-day pre-embarkation AGE illness assessment.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 95 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-250	250
Annual IC Time Burden (Hours)	-4	4
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.