ALS Medical Record Verification Form

Creation of State and Metropolitan Area Based Surveillance Projects for Amyotrophic Lateral Sclerosis (ALS)

Documents and Forms

Document Name Document Type
ALS Medical Record Verification Form Form
Medical Record Verification Form Attachment 4 Medical Record Verification Form (2).docx Form

Information Collection (IC) Details

IC Title:	ALS Medical Record Verification Form	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Medical Record Verification Form	Attachment 4 Medical Record Verification Form (2).docx		No	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 57 FR 62712

Number of Respondents: 450	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	450	450
Annual IC Time Burden (Hours)	150	150
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.