Food Record Form

Salt Sources Study

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0982 can be found here:

Documents and Forms

Document Name Document Type
Food Record Form Form
Food Record Form Att 12A_Food Record Form.docx Form
Att 12B_Food Record Instructions.docx Att 12B_Food Record Instructions IC Document

Information Collection (IC) Details

IC Title:	Food Record Form	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	Food Record Form	Att 12A_Food Record Form.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 252

Number of Respondents: 225	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	225	225
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 12B_Food Record Instructions	Att 12B_Food Record Instructions.docx	06/04/2013

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