Information Collection

Provider-Based: Pre-Pregnancy Visit

IC 193555 under ICR 201101-0925-004 · OMB 0925-0593.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0593 can be found here:

Documents and Forms

Document Name Document Type
Form 4 Provider-Based: Pre-Pregnancy Visit Form and Instruction
4 Survey Pre-pregnancy interview July Launch 20100607a.docx Form and Instruction
Pre--pregnancy interview July Launch VIS 20100615.pdf Pre--pregnancy interview July Launch VIS 20100615 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider-Based: Pre-Pregnancy Visit	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	4	Survey	Pre-pregnancy interview July Launch 20100607a.docx		Yes	Yes	Paper Only

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 123	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	123	123
Annual IC Time Burden (Hours)	92	92
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Pre--pregnancy interview July Launch VIS 20100615	Pre--pregnancy interview July Launch VIS 20100615.pdf	06/15/2010

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