Information Collection

Congenital Syphilis Case Investigation and Report Form

IC 6642 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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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

Is this a Common Form? No		IC Status: Modified

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
Instruction			0920-0128 Attachment 5.2a CDC73 126.pdf		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	400	-100	500
Annual IC Time Burden (Hours)	100	-30	130
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.