DOG EXPOSURE QUESTIONNAIRE - State and Local Health Department Staff

Enhanced surveillance for cases linked to a multistate outbreak of multidrug-resistant Campylobacter infections linked to contact with pet store puppies

Documents and Forms

Document Name Document Type
Form 0920-XXXX DOG EXPOSURE QUESTIONNAIRE - State and Local Health Department Staff Form and Instruction
0920-XXXX Dog Exposure Questionnaire 3. Dog exposure questionnaire.docx Form and Instruction

Information Collection (IC) Details

IC Title:	DOG EXPOSURE QUESTIONNAIRE - State and Local Health Department Staff	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	0920-XXXX	Dog Exposure Questionnaire	3. Dog exposure questionnaire.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	25	25
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.