Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Consent for Bloodspot Retrieval Modified 1375 344 0 Form and Instruction none Consent for Bloodspot Release
Form and Instruction none Consent for Bloodspot Retrieval - Spanish
Form and Instruction none Consent for Bloodspot Retrieval - Multiples
Form and Instruction none Consent for Bloodspot Retrieval - Multiples - Spanish
Intro Phone Script including Consent to Supplemental Stillbirth New 710 296 0 Other-WORD
Other-Word
Form N/A Supplemental Stillbirth Computer Assisted Telephone Interview
Form N/A Supplemental Stillbirth Computer Assisted Telphone Interview
Medical Record Request Modified 475 119 0 Form none Medical Record Release Authorization
Form none Medical Record Release Authorization
Medical Record Review Modified 475 238 0 Instruction
Mother's Questionnaire Modified 2365 1774 0 Form none BD-STEPS Questionnaire
Form none BD-STEPS Questionnaire - Spanish
Occupational Questionnaires Modified 790 263 0 Form none Agriculture Questionnaire
Form none Electronic Equipment Operator Questionnaire
Form none Cosmetology Questionnaire
Form none Healthcare Questionnaire
Form none Housekeeping Questionnaire
Form none Office Work Questionnaire
Form none Restaurant Work Questionnaire
Form none Teacher Questionnaire
Total burden requested under this ICR: 6190 3034 0  
To view an IC, click on IC Title