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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
2018 Congenital Syphilis Study
Agency IC Tracking Number:
0920-0840-18YY
IC Status:
New
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
0920-0840
Eligibility Screener - Prenatal Care Providers
Att 5a-Eligibility Screener Providers.docx
NA
No
Paper Only
Form and Instruction
0920-0840
Interview Guide - Prenatal Care Providers
Att 5b-Interview guide Providers.docx
NA
No
Paper Only
Form and Instruction
0920-0840
Eligibility Sreener - Pregnant Women
Att 5c-Eligibility Screener Preg Women.docx
NA
No
Paper Only
Form and Instruction
0920-0840
Interview Guide - Pregnant Women
Att 5d-Interview guide Preg Women.docx
NA
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
09-20-0136 - Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 62812
Number of Respondents:
220
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
220
0
220
0
0
0
Annual IC Time Burden (Hours)
220
0
220
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Recruitment Flyer
Att 3- Recruitment Flyer.pdf
04/10/2018
Interview Consent Form
Att 4a- Interview Consent Form.pdf
04/10/2018
Focus Group Consent Form
Att 4b- Focus Group Consent Form.pdf
04/10/2018
Audio Consent Form
Att 4c- Audio Consent Form.pdf
04/10/2018
UCSD IRB Approval Letter
Att 6a-UCSD IRB Letter of Approval.pdf
04/10/2018
Tulane IRB Approval Letter
Att 6b-Tulane IRB Letter of Approval.pdf
04/10/2018
Research Plan
Att 7- Research Plan.docx
04/10/2018
CDC Project Determination
Att 8-PD 7088 2018 Congenital Syphilis Study Project-Determination-and-Approval-Form-1.._.pdf
04/10/2018
Privacy Impact Assessment
Att 9-PIA CongenitalSyphils.pdf
04/10/2018
Supporting Statement A
SSA 11APR2018.docx
04/11/2018
Supporting Statement B
SSB 11APR2018.docx
04/11/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.