Information Collection

Congenital Syphilis Case Investigation and Report Form

IC 46587 under ICR 200612-0920-012 · OMB 0920-0128.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0920-0128 Attachment 5.2a CDC73 126.pdf	Instruction
0920-0128 Attachment 5.2b CDC73 126.pdf 0920-0128 Attachment 5	IC Document

IC Title:

Congenital Syphilis Case Investigation and Report Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			0920-0128 Attachment 5.2a CDC73 126.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0920-0128 Attachment 5	0920-0128 Attachment 5.2b CDC73 126.pdf	12/15/2006

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