Adult Symptom Diary

[ATSDR] Evaluating the Association between Serum Concentrations of Per- and Polyfluoroalkyl Substances (PFAS) and Symptoms and Diagnoses of Selected Acute Viral Illnesses

Documents and Forms

Document Name Document Type
Form 0923-22BJ Adult Symptom Diary Form and Instruction
0923-22BJ Symptom Diary P_ApndxE_SymptmDiary_11092021.docx Form and Instruction
0923-22BJ Symptom Diary P_ApndxE_SymptmDiary_11092021.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Adult Symptom Diary	Agency IC Tracking Number:	0923-22BJ

Is this a Common Form? No		IC Status: Unchanged

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	0923-22BJ	Symptom Diary	P_ApndxE_SymptmDiary_11092021.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Records of Persons Exposed or Potentially Exposed to Hazardous or Toxic Substances (retrievable by name or SSN)	FR Citation: 76 FR 4431

Number of Respondents: 1,400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,400	1,400
Annual IC Time Burden (Hours)	5,600	5,600
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.