PILOT Participants Survivor Questionnaire

Persistence of Ebola Virus in Body Fluids of Ebola Virus Disease Survivors in Sierra Leone

Documents and Forms

Document Name Document Type
PILOT Participants Survivor Questionnaire Form and Instruction
Survivor Questionnaire - Pilot/A/B Att5_SurvivorQuestionnaire 20150518 clean.docx Form and Instruction

Information Collection (IC) Details

IC Title:	PILOT Participants Survivor Questionnaire	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 and Instruction	None	Survivor Questionnaire - Pilot/A/B	Att5_SurvivorQuestionnaire 20150518 clean.docx	None	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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	100	100
Annual IC Time Burden (Hours)	50	50
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.