Information Collection

Congenital Syphilis (CS) Case Investigation and Report Form: Local Health Department

IC 6642 under ICR 201002-0920-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0128 Congenital Syphilis (CS) Case Investigation and Report Form: Local Health Department	Form and Instruction
0920-0128 Congenital Syphilis (CS) Case Investigation and Report F 0920-0128_Attachment3b CSform2.pdf	Form and Instruction

IC Title:

Congenital Syphilis (CS) Case Investigation and Report Form: Local Health Department

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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
Form and Instruction	0920-0128	Congenital Syphilis (CS) Case Investigation and Report Form	0920-0128_Attachment3b CSform2.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	110	-290	400
Annual IC Time Burden (Hours)	37	-63	100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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