Information Collection

Record Keeping for sterilization consent forms

IC 191181 under ICR 201210-0937-001 · OMB 0937-0166.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0937-0166 can be found here:

Documents and Forms

Document Name Document Type
Form 0937-0166 Record Keeping for sterilization consent forms Form
0937-0166 Sterilization form 0937-0166sterilization consent form OMB 11 2009 approval.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Record Keeping for sterilization consent forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 50.Sub Part B

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0937-0166	Sterilization form	0937-0166sterilization consent form OMB 11 2009 approval.doc		No	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100,000	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	100,000	100,000
Annual IC Time Burden (Hours)	25,000	25,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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