Medication Form

Anniston Community Health Survey: Follow up and Dioxin Analyses (ACHS-II)

Documents and Forms

Document Name Document Type
Att3.10_MedicationForm.docx Other-WORD
Att3_6_ReminderTelScript_20131205.docx Att3_6_ReminderTelScript_20131205 IC Document

Information Collection (IC) Details

IC Title:	Medication 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
Other-WORD			Att3.10_MedicationForm.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 09-19-0001 Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 53 FR 30720

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att3_6_ReminderTelScript_20131205	Att3_6_ReminderTelScript_20131205.docx	12/09/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.