Passenger Locator Form (Domestic)

Report of Illness or Death: Interstate Travel of Persons (42 CFR part 70)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0488 can be found here:

Documents and Forms

Document Name Document Type
Passenger Locator Form (Domestic) Form
Passenger Locator Attachment 3 Passenger Locator Form.docx Form

Information Collection (IC) Details

IC Title:	Passenger Locator Form (Domestic)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	Passenger Locator	Attachment 3 Passenger Locator Form.docx		No		Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 09-20-0171 Quarantine and Traveler Related Activities, Inlcuding Records for Contact Tracing Investingations	FR Citation: 72 FR 7086

Number of Respondents: 800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-800	800
Annual IC Time Burden (Hours)	-67	67
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.