Tick-borne Rickettsial Disease Case Report

National Disease Surveillance Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0009 can be found here:

Documents and Forms

Document Name Document Type
Form none assigned Tick-borne Rickettsial Disease Case Report Form
none assigned Tick-Borne Tickborne case_Rep_Fm.pdf Form

Information Collection (IC) Details

IC Title:	Tick-borne Rickettsial Disease Case Report	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 assigned	Tick-Borne	Tickborne case_Rep_Fm.pdf		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems 09-20-0136	FR Citation: 57 FR 62812

Number of Respondents: 55	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	990	990
Annual IC Time Burden (Hours)	165	165
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.