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Enrollment Questionnaire for Clinics and Shelter
Canine Leptospirosis Surveillance in Puerto Rico
OMB: 0920-1170
IC ID: 225035
OMB.report
HHS/CDC
OMB 0920-1170
ICR 201903-0920-008
IC 225035
( )
Documents and Forms
Document Name
Document Type
Form 0920-1170
Enrollment Questionnaire for Clinics and Shelter
Form and Instruction
0920-1170 Site Enrollment Questionnaire
Att C - Site Enrollment Questionnaire ENGLISH.docx
Form and Instruction
0920-1170 Site Enrollment Quesionnaire Spanish
Att C - Site Enrollment Questionnaire SPANISH.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Enrollment Questionnaire for Clinics and Shelter
Agency IC Tracking Number:
16BGH
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 and Instruction
0920-1170
Site Enrollment Questionnaire
Att C - Site Enrollment Questionnaire ENGLISH.docx
No
Fillable Fileable
Form and Instruction
0920-1170
Site Enrollment Quesionnaire Spanish
Att C - Site Enrollment Questionnaire SPANISH.docx
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 62812
Number of Respondents:
26
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
26
0
0
0
26
0
Annual IC Time Burden (Hours)
2
0
0
0
2
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.