Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
(CREW) 72-hour Food/Activity History Template (AGE cases) New 17250 2875 0 Form and Instruction 0920-1260 72-hour Food/Activity History Template (AGE cases)
(Passenger) 72-hour Food/Activity History Template (AGE cases) New 83850 13975 0 Form and Instruction 0920-1260 72-hour Food/Activity History Template (AGE cases)
71.21 (c) 72-hour food/activity history - AGE Passenger and Crew cases Removed 0 0 0 Form and Instruction NA 72-hr Food/Activity History Template
71.21 (c) AGE Logs Removed 0 0 0 Form and Instruction NA VSP AGE Log
71.21 (c) Documentation of 3-day pre-embarkation AGE illness assessment for all crew members Removed 0 0 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 Removed 0 0 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 Removed 0 0 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) Removed 0 0 0 Form and Instruction NA Gastrointestinal Illness Surveillance System Questionnaire
71.21 (c) Recordkeeping – medical records (AGE Logs) Removed 0 0 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) Removed 0 0 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) Removed 0 0 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) Removed 0 0 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 Removed 0 0 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) Removed 0 0 0 Form and Instruction NA Documentation of 3-day pre-embarkation AGE illness assessment
AGE Illness Report 24 hours before arrival (phone/email/fax) New 5040 252 0 Form and Instruction 0920-1260 AGE Illness Report 24 hours before arrival (phone/email/fax)
AGE Illness Report 24 hours before arrival (web) New 3960 198 0 Form and Instruction 0920-1260 AGE Illness Report 24 hours before arrival (web)
AGE Illness Report 4 hours before arrival (phone/email/fax) New 4020 201 0 Form and Instruction 0920-1260 Att5a2 4 hr AGEIllnssRprt (phone email fax) 20220125
AGE Illness Report 4 hours before arrival (web) New 3180 159 0 Form and Instruction 0920-1260 AGE Illness Report 4 hours before arrival (web)
Daily Reports of AGE Logs New 2160 108 0 Form and Instruction 0920-1260 Daily Reports of AGE Logs
Interviews to Determine AGE Status (initial, 24-hr, 48-hr)(asymptomatic cabin mates and immediate contacts of symptomatic crew) New 251550 21562 0 Form and Instruction 0920-1260 Interviews to Determine AGE Status (initial, 24-hr, 48-hr)(asymptomatic cabin mates and immediate contacts of symptomatic crew)
Last Symptom Check and Return to Work Clearance (food and nonfood employees) New 17250 862 0 Form and Instruction 0920-1260 Last Symptom Check and Return to Work Clearance (food and nonfood employees)
Recordkeeping of AGE Surveillance Records New 300 2628000 0 Form and Instruction 0920-1260 Recordkeeping of AGE Surveillance Records
Recordkeeping of Engineering and Sanitation Records New 300 2628000 0 Form and Instruction 0920-1260 Recordkeeping of Engineering and Sanitation Records
Special Reports exceeding 2%-3% AGE Threshold (web/phone/email/fax) New 720 36 0 Form and Instruction 092-1260 Special Reports exceeding 2%-3% AGE Threshold (web/phone/email/fax)
Three-day Pre-embarkation AGE Illness Assessment (all crew members) New 9720000 486000 0 Form and Instruction 0920-1260 Three-day Pre-embarkation AGE Illness Assessment (all crew members)
Total burden requested under this ICR: 10109580 5782228 0  
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