Information Collection

Congenital Syphilis (CS) Case Investigation and Report Form

IC 6641 under ICR 200005-0920-004 · OMB 0920-0128.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0128 can be found here:

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Information Collection (IC) Details

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IC Title:	Congenital Syphilis (CS) Case Investigation and Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CDC-73.126				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 65	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,000	-1,000	2,000
Annual IC Time Burden (Hours)	260	-240	500
Annual IC Cost Burden (Dollars)	0	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.