Information Collection

Consent Form

IC 187723 under ICR 200901-0920-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form No number Consent Form	Form
No number Consent form for Pregnant Women Attachment C2a 102108.doc	Form
Attachment C2b 102108.doc Consent Form for Breastfeeding Women	IC Document

IC Title:

Consent Form

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR USC 241 42 CFR USC 247 (To search for a specific CFR, visit the Code of Federal Regulations.)

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
Form	No number	Consent form for Pregnant Women	Attachment C2a 102108.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Form for Breastfeeding Women	Attachment C2b 102108.doc	11/05/2008

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