SAMPLE VHF Symptom Monitoring Web Survey

[NCZEID] Traveler Risk Assessment and Management Activities During Disease Outbreaks

Documents and Forms

Document Name Document Type
Form 0920-25-0004 SAMPLE VHF Symptom Monitoring Web Survey Form and Instruction
0920-25-0004 Attachment E3 - SAMPLE VHF Symptom Monitoring Web Survey Attachment E3 - SAMPLE VHF Symptom Monitoring Web Survey.docx Form and Instruction

Information Collection (IC) Details

IC Title:	SAMPLE VHF Symptom Monitoring Web Survey	Agency IC Tracking Number:	0920-25-0004

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

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	0920-25-0004	Attachment E3 - SAMPLE VHF Symptom Monitoring Web Survey	Attachment E3 - SAMPLE VHF Symptom Monitoring Web Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,298	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12,894	12,894
Annual IC Time Burden (Hours)	1,232	1,232
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.