Information Collection

SEED - Medical Record Abstraction

IC 178550 under ICR 201005-0920-003 · OMB 0920-0741.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix_S.1 Study Start MR release letter - child 2007.doc	Other-WORD
Appendix_S.1 Study Start MR script & fax letter2007.doc	Other-WORD
Appendix_S.1 Study Start MR release letter - mom 2007.doc	Other-WORD
Appendix_S.1.1 CADDRE study start medical records release cover sheets.doc	Other-WORD
Appendix_S.2 Prenatal MR Form FINAL STUDY START VERSION.doc Appendix_S	IC Document
Appendix_S.3 Labor and Delivery MR Form Final.doc Appendix_S	IC Document
Appendix_S.4 NEONATAL FORM FINAL.DOC Appendix_S	IC Document
Appendix_S.5 PEDIATRIC FORM 3.6.09 FINAL.DOC Appendix_S	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD	Appendix_S.1 Study Start MR release letter - child 2007.doc	Yes	Yes	Fillable Printable
Other-WORD	Appendix_S.1 Study Start MR script & fax letter2007.doc	Yes	Yes	Fillable Printable
Other-WORD	Appendix_S.1 Study Start MR release letter - mom 2007.doc	Yes	Yes	Fillable Printable
Other-WORD	Appendix_S.1.1 CADDRE study start medical records release cover sheets.doc	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 347

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,735	-15,545	17,280
Annual IC Time Burden (Hours)	87	-4,233	4,320
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix_S	Appendix_S.2 Prenatal MR Form FINAL STUDY START VERSION.doc	04/27/2010
Appendix_S	Appendix_S.3 Labor and Delivery MR Form Final.doc	04/27/2010
Appendix_S	Appendix_S.4 NEONATAL FORM FINAL.DOC	04/27/2010
Appendix_S	Appendix_S.5 PEDIATRIC FORM 3.6.09 FINAL.DOC	04/27/2010

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