ALS Medical Record Verification Form

Creation of State and Metropolitan Area Based Surveillance Projects for Amyotrophic Lateral Sclerosis (ALS)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0043 can be found here:

Documents and Forms

Document Name Document Type
ALS Medical Record Verification Form Form
Medical Record Verification Form Attachment 4 Medical Record Verification Form (2).docx Form

Information Collection (IC) Details

IC Title:	ALS Medical Record Verification Form	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	none	Medical Record Verification Form	Attachment 4 Medical Record Verification Form (2).docx		No	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 57 FR 62712

Number of Respondents: 450	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	450	450
Annual IC Time Burden (Hours)	150	150
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.