Information Collection

Provider-Based: Pre-Pregnancy Interview

IC 193555 under ICR 201103-0925-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 5.1 Survey Provider-Based: Pre-Pregnancy Interview	Form and Instruction
Refusal of Bio Env Samples 20110211.docx	Instruction
5.1 Survey Pre-Pregnancy Interview 20110211.doc	Form and Instruction
Pre-Pregnancy Visit Information Sheet 20110211.docx Pre-Pregnancy Visit Information Sheet 20110211	IC Document

IC Title:

Provider-Based: Pre-Pregnancy Interview

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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5.1				Yes	Yes	Paper Only
Instruction					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 %

table that charts list of burden
	Requested	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

table that charts IC Documents
Title	Document	Date Uploaded
Pre-Pregnancy Visit Information Sheet 20110211		02/11/2011

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

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