Mothers

Evaluation of Pregnant and Postpartum Women (PPW)

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.