Birth Certificate and Hospital Discharge Linkage - State Survey

Surveys of State, Tribal, Local and Territorial (STLT) Governmental Health Agencies

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Document Name Document Type
Birth Certificate and Hospital Discharge Linkage - State Survey Form
Birth Certificate and Hospital Discharge Survey - AMCHP Attachment C_AMCHP Screenshots_8 14 2012.doc Form
Birth Certificate and Hospital Discharge - NAPHSIS Attachment B_NAPHSIS Screenshots_8 14 2012.docx Form
DRH_Supporting Statement A_8 24 2012.docx Supporting Statement A IC Document
DRH_Supporting Statement B_8 24 2012.docx Supporting Statement B IC Document
Attachment A_Survey Questions_8_14 2012.docx Birth Certificate and Hospital Discharge - Word version IC Document
Attachment D_Advance Survey Notification Email_8 14 2012.docx Att D - Advance Emails IC Document
Attachment E_Survey Notification Email_8 14 2012.docx Att E - Notification Emails IC Document
Attachment F_Reminders (Email and Telephone)_8 24 2012.docx Att F - Reminders IC Document

Information Collection (IC) Details

IC Title:	Birth Certificate and Hospital Discharge Linkage - State Survey	Agency IC Tracking Number:

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	none	Birth Certificate and Hospital Discharge Survey - AMCHP	Attachment C_AMCHP Screenshots_8 14 2012.doc		Yes	Yes	Fillable Fileable
Form	none	Birth Certificate and Hospital Discharge - NAPHSIS	Attachment B_NAPHSIS Screenshots_8 14 2012.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 104	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	104	0	0	0	0	0
Annual IC Time Burden (Hours)	43	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	DRH_Supporting Statement A_8 24 2012.docx	08/27/2012
Supporting Statement B	DRH_Supporting Statement B_8 24 2012.docx	08/27/2012
Birth Certificate and Hospital Discharge - Word version	Attachment A_Survey Questions_8_14 2012.docx	08/27/2012
Att D - Advance Emails	Attachment D_Advance Survey Notification Email_8 14 2012.docx	08/27/2012
Att E - Notification Emails	Attachment E_Survey Notification Email_8 14 2012.docx	08/27/2012
Att F - Reminders	Attachment F_Reminders (Email and Telephone)_8 24 2012.docx	08/27/2012

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