CryptoNet Case Report Form

[NCEZID] CryptoNet Case Report Form

Documents and Forms

Document Name Document Type
CryptoNet Case Report Form Form and Instruction
CryptoNet Case Report Form Att C_CryptoNet Case Report Form_2024 version - CLEAN.docx Form and Instruction

Information Collection (IC) Details

IC Title:	CryptoNet Case Report 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 and Instruction	n/a	CryptoNet Case Report Form	Att C_CryptoNet Case Report Form_2024 version - CLEAN.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	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	Previously Approved
Annual Number of Responses for this IC	500	0	500
Annual IC Time Burden (Hours)	125	0	125
Annual IC Cost Burden (Dollars)	0	-3,215	3,215

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.