Health Facility Assessment and Case Finding Survey

2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1033 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-15CN Health Facility Assessment and Case Finding Survey Form and Instruction
0920-15CN Attachment M_Health Facility Assessment and Case Finding Attachment M_Health Facility Assessment and Case Finding Survey.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Health Facility Assessment and Case Finding Survey	Agency IC Tracking Number:	0920-15CN

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	0920-15CN	Attachment M_Health Facility Assessment and Case Finding Survey	Attachment M_Health Facility Assessment and Case Finding Survey.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Ebola Emergency Investigation Case Records Systems Notice	FR Citation: 51 FR 42466

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
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.