Information Collection

Pregnancy Visit 1 Interview (PB, EH, TT-HI, PBS)

IC 193565 under ICR 201211-0925-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 8.3 Pregnancy Visit 1 Interview (PB, EH, TT-HI, PBS) Form and Instruction
8.3 Survey Attach A1. PLSND Interview.docx Form and Instruction
8.4 Survey Attach A2. PLSND Follow-Up SAQ.docx Form and Instruction
8.1 Survey Attach A12. Pregnancy Visit 1 Interview.docx Form and Instruction
8.2 Survey Attach A14. Pregnancy Visit 1 SAQ.docx Form and Instruction
Pregnancy Visit 1 Visit Information Sheet.docx Pregnancy Visit 1 Visit Information Sheet IC Document
Attach A3. PLSND Medical Records Release Form.docx Attach A3. PLSND Medical Records Release Form IC Document
Attach A4. PLSND Death Certificate Release Form.docx Attach A4. PLSND Death Certificates Release Form IC Document
Attach A5. PLSND Item NR Rates.docx Attach A5. PLSND Item NR Rates IC Document
Attach A6. PLSND Follow-Up SAQ and Release Forms Letter.docx Attach A6. PLSND Follow-Up SAQ and Release Forms Letter IC Document
Attach A7. PLSND Telephone Medical Records Release Forms Letter.docx Attach A7. PLSND Telephone Medical Records Release Forms Letter IC Document
Attach A8. PLSND Telephone Medical Records and Death Cert Release.docx Attach A8. PLSND Telephone Medical Records and Death Cert Release IC Document
Attach A9. PLSND Mail Reminder Call Script.docx Attach A9. PLSND Mail Reminder Call Script IC Document
Attach A10. PLSND Telephone Reminder Call Script.docx Attach A10. PLSND Telephone Reminder Call Script IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pregnancy Visit 1 Interview (PB, EH, TT-HI, PBS)	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	8.3	Survey	Attach A1. PLSND Interview.docx	Yes	Yes	Paper Only
Form and Instruction	8.4	Survey	Attach A2. PLSND Follow-Up SAQ.docx	Yes	Yes	Fillable Printable
Form and Instruction	8.1	Survey	Attach A12. Pregnancy Visit 1 Interview.docx	Yes	Yes	Paper Only
Form and Instruction	8.2	Survey	Attach A14. Pregnancy Visit 1 SAQ.docx	Yes	Yes	Fillable Printable

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: 2,018	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	2,018	2,018
Annual IC Time Burden (Hours)	1,177	1,177
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Pregnancy Visit 1 Visit Information Sheet	Pregnancy Visit 1 Visit Information Sheet.docx	04/13/2012
Attach A3. PLSND Medical Records Release Form	Attach A3. PLSND Medical Records Release Form.docx	10/19/2012
Attach A4. PLSND Death Certificates Release Form	Attach A4. PLSND Death Certificate Release Form.docx	10/19/2012
Attach A5. PLSND Item NR Rates	Attach A5. PLSND Item NR Rates.docx	10/19/2012
Attach A6. PLSND Follow-Up SAQ and Release Forms Letter	Attach A6. PLSND Follow-Up SAQ and Release Forms Letter.docx	10/19/2012
Attach A7. PLSND Telephone Medical Records Release Forms Letter	Attach A7. PLSND Telephone Medical Records Release Forms Letter.docx	10/19/2012
Attach A8. PLSND Telephone Medical Records and Death Cert Release	Attach A8. PLSND Telephone Medical Records and Death Cert Release.docx	10/19/2012
Attach A9. PLSND Mail Reminder Call Script	Attach A9. PLSND Mail Reminder Call Script.docx	10/19/2012
Attach A10. PLSND Telephone Reminder Call Script	Attach A10. PLSND Telephone Reminder Call Script.docx	10/19/2012

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