Congenital Syphilis Case Investigation and Report Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
0920-0128 revised Supporting Statement 12 08 06.doc	Supporting Statement A	Uploaded 2006-12-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6642	Congenital Syphilis Case Investigation and Report Form	Instruction	Modified
46587	Congenital Syphilis Case Investigation and Report Form	Instruction	New

ICR Details

OMB Control No: 0920-0128	ICR Reference No: 200612-0920-012
Status: Historical Active	Previous ICR Reference No: 200307-0920-008
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Congenital Syphilis Case Investigation and Report Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/16/2007
	Date Received in OIRA: 12/29/2006
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2010	36 Months From Approved	02/28/2007
Responses	520	0	500
Time Burden (Hours)	160	0	130
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this report is to collect surveillance data on congenital syphilis (CS) cases from state and local health departments nationwide. The data are used by health care planners at the national, state and local levels to develop and evaluate CS prevention and control programs. In addition, there are many other users of the data including scientists, researchers, educators, students and the media.

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Authorizing Statute(s): US Code: 5 USC 301 Name of Law: General Research and Investigation
   US Code: 5 USC 318 Name of Law: Sexually Transmitted Diseases
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 177	09/13/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 75257	12/14/2006
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Congenital Syphilis Case Investigation and Report Form
Congenital Syphilis Case Investigation and Report Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	520	500	0	20	0	0
Annual Time Burden (Hours)	160	130	0	30	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: No major changes made.

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Annual Cost to Federal Government: $3

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/21/2006

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