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Health Questionnaire
Factors Influencing the Transmission of Influenza
OMB: 0920-0888
IC ID: 196082
OMB.report
HHS/CDC
OMB 0920-0888
ICR 202101-0920-010
IC 196082
( )
Documents and Forms
Document Name
Document Type
Health Questionnaire
Form
Health Questionnaire for study "Factors Influencing the
Attachment 5 - Health Questionnaire_2021-2-16.docx
Form
Health Questionnaire for study "Factors Influencing the
Attachment 5 - Health Questionnaire_2021-2-16.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Health Questionnaire
Agency IC Tracking Number:
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
n/a
Health Questionnaire for study "Factors Influencing the Transmission of Influenza"
Attachment 5 - Health Questionnaire_2021-2-16.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
Occupational Health Epidemiological Studies and EEOICPA Records
FR Citation:
76 FR 34706
Number of Respondents:
90
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
90
0
0
0
0
90
Annual IC Time Burden (Hours)
8
0
0
0
0
8
Annual IC Cost Burden (Dollars)
109
0
109
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.