Serologic Survey for Vibrio cholerae Infection in Haiti with Assessment of Risk Factors for Asymptomatic, Mild, Moderate, and Severe Disease

Documents and Forms

Document Name Document Type
Form 1 Serologic Survey for Vibrio cholerae Infection in Haiti with Assessment of Risk Factors for Asymptomatic, Mild, Moderate, and Severe Disease Form and Instruction
1 Survey Instrument Appendix Questionnaires 1-10-11.docx Form and Instruction
Appendix Consent Forms.docx Appendix Consent Forms IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Serologic Survey for Vibrio cholerae Infection in Haiti with Assessment of Risk Factors for Asymptomatic, Mild, Moderate, and Severe Disease	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	1	Survey Instrument	Appendix Questionnaires 1-10-11.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,400	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	2,400	2,400
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix Consent Forms	Appendix Consent Forms.docx	01/18/2011

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