Baseline survey

[NCEZID] Oropouche Virus Disease Outbreak

Documents and Forms

Document Name Document Type
Form 0920-25AU Baseline survey Form and Instruction
0920-25AU INITIAL CLINCAL AND SOCIAL SURVEY Att. 3 Initial Clinical and Social Survey_Revised.docx Form and Instruction
0920-25AU INITIAL CLINCAL AND SOCIAL SURVEY Att. 3 Initial Clinical and Social Survey_Revised.docx Form and Instruction
0920-1446 INITIAL CLINCAL AND SOCIAL SURVEY_04DEC2024 Att. 3 Initial Clinical and Social Survey_Clean_29Nov2024.docx Form and Instruction
0920-1446 INITIAL CLINCAL AND SOCIAL SURVEY_04DEC2024 Att. 3 Initial Clinical and Social Survey_Clean_29Nov2024.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Baseline survey	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 and Instruction	0920-25AU	INITIAL CLINCAL AND SOCIAL SURVEY	Att. 3 Initial Clinical and Social Survey_Revised.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1446	INITIAL CLINCAL AND SOCIAL SURVEY_04DEC2024	Att. 3 Initial Clinical and Social Survey_Clean_29Nov2024.docx	N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	100	100
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.