United States Travel Health Declaration (English:hard copy, fillable PDF, electonic Portal)

Emergency Submission to Supplement OMB Control Number 0920-0821 in the context of Screening Travelers for Ebola Risk

Documents and Forms

Document Name Document Type
Form 0920-1031 United States Travel Health Declaration (English:hard copy, fillable PDF, electonic Portal) Form and Instruction
0920-1031 Attachment A1a DHS Form United States Traveler Health De Attachment A1a DHS Form United States Traveler Health Declaration - English.doc Form and Instruction
0920-1031 Attachment A1b DHS Form United States Traveler Health De Attachment A1b DHS Form United States Traveler Health Dec - electronic portal screenshot.png Form and Instruction
0920-1031 Attachment A1c DHS Form United States Traveler Health De Attachment A1c DHS Form United States Traveler Health Declaration - fillable PDF.pdf Form and Instruction
Attachment A1b DHS Form United States Traveler Health Dec - electronic portal word ver.docx Attachment A1b DHS Form United States Traveler Health Dec - electronic portal word ver IC Document

Information Collection (IC) Details

IC Title:	United States Travel Health Declaration (English:hard copy, fillable PDF, electonic Portal)	Agency IC Tracking Number:	0920-15FM

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1031	Attachment A1c DHS Form United States Traveler Health Declaration - fillable PDF	Attachment A1c DHS Form United States Traveler Health Declaration - fillable PDF.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1031	Attachment A1a DHS Form United States Traveler Health Declaration - English	Attachment A1a DHS Form United States Traveler Health Declaration - English.doc	Yes	Yes	Fillable Printable
Form and Instruction	0920-1031	Attachment A1b DHS Form United States Traveler Health Dec - electronic portal screenshot	Attachment A1b DHS Form United States Traveler Health Dec - electronic portal screenshot.png	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 22,663	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	22,663	22,663
Annual IC Time Burden (Hours)	5,666	5,666
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment A1b DHS Form United States Traveler Health Dec - electronic portal word ver	Attachment A1b DHS Form United States Traveler Health Dec - electronic portal word ver.docx	11/19/2014

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