Information Collection

Mothers

IC 195008 under ICR 201010-0930-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Instruments for Mo Mothers	Form and Instruction
Instruments for Mo Instruments for Mothers Attachment A-1 - Instruments for Mothers.pdf	Form and Instruction
Attachment A-2 - Supporting Documents for Mothers.pdf Supporting Documents for Mothers	IC Document

IC Title:

Mothers

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	Instruments for Mothers	Instruments for Mothers	Attachment A-1 - Instruments for Mothers.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 440

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	19,756	19,756
Annual IC Time Burden (Hours)	6,700	6,700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Documents for Mothers	Attachment A-2 - Supporting Documents for Mothers.pdf	10/06/2010

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