Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
71.21 (c) 72-hour food/activity history - AGE Passenger and Crew cases New 5000 833 0 Form and Instruction NA 72-hr Food/Activity History Template
71.21 (c) AGE Logs New 2500 417 0 Form and Instruction NA VSP AGE Log
71.21 (c) Documentation of 3-day pre-embarkation AGE illness assessment for all crew members New 1250 63 0 Form and Instruction NA Documentation of 3-day pre-embarkation AGE illness assessment
71.21 (c) Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees New 250 13 0 Form and Instruction NA Documentation of Last Symptom and Clearance to Return to Work
71.21 (c) Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times New 750 63 0 Form and Instruction NA Documentation of Interviews with AGE Crew Case Cabin Mates and Immediate Contacts to Determine AGE Illness Status
71.21 (c) Recordkeeping - medical records (72-hour food/activity history) New 250 4 0 Form and Instruction NA Gastrointestinal Illness Surveillance System Questionnaire
71.21 (c) Recordkeeping – medical records (AGE Logs) New 250 4 0 Form and Instruction NA VSP AGE Log
71.21 (c) Recordkeeping – medical records (Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees) New 250 4 0 Form and Instruction NA Documentation of Last Symptom and Clearance to Return to Work
71.21 (c) Recordkeeping – medical records (Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times) New 250 4 0 Form and Instruction NA Documentation of Interviews with AGE Crew Case Cabin Mates and Immediate Contacts to Determine AGE Illness Status
71.21(c) Gastrointestinal Illness Report - 24 and 4 hours before arrival (MIDRS) New 2500 125 0 Form and Instruction NA Gastrointestinal Illness (GI) Template
Form and Instruction NA MIDRS Template - screenshot
71.21(c) Recordkeeping - Gastrointestinal Illnesses Report 24 and 4 hours before arrival New 250 4 0 Form and Instruction NA Recordkeeping - MIDRS Template
71.21(c) Recordkeeping - medical records (Documentation of 3-day pre-embarkation AGE illness assessment for all crew members) New 250 4 0 Form and Instruction NA Documentation of 3-day pre-embarkation AGE illness assessment
Total burden requested under this ICR: 13750 1538 0  
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