Congenital Syphilis Case Investigation and Report Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Congenital Syphilis (CS) Case Investigation and Report Form: Local Health Department	Form	Modified	Available
Congenital Syphilis (CS) Case Investigation and Report Form Territorial Health Agencies	Form	Modified	Available
Congenital Syphilis (CS) Case Investigation and Report Form: City and county health departments	Form	Modified	Available
SupportB.doc	Supporting Statement B	Uploaded 2012-12-10	Available
Att3b Instrument.doc	Supplementary Document	Uploaded 2012-12-05	Available
Att3a DataElements.doc	Supplementary Document	Uploaded 2012-12-05	Available
Att5 PublicationList.doc	Supplementary Document	Uploaded 2012-12-05	Repair queued
Att4 DataReleaseGuidelines.doc	Supplementary Document	Uploaded 2012-12-05	Available
Att2_60Day FRN.pdf	Supplementary Document	Uploaded 2012-12-05	Available
Att1 Auth Legis.doc	Supplementary Document	Uploaded 2012-12-05	Available
SupportA.doc	Supporting Statement A	Uploaded 2012-12-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6642	Congenital Syphilis (CS) Case Investigation and Report Form: Local Health Department	Form	Modified
46587	Congenital Syphilis (CS) Case Investigation and Report Form Territorial Health Agencies	Form	Modified
192057	Congenital Syphilis (CS) Case Investigation and Report Form: City and county health departments	Form	Modified

ICR Details

OMB Control No: 0920-0128	ICR Reference No: 201212-0920-005
Status: Historical Active	Previous ICR Reference No: 201002-0920-007
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Congenital Syphilis Case Investigation and Report Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/09/2013
	Date Received in OIRA: 12/10/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	36 Months From Approved	03/31/2013
Responses	187	0	187
Time Burden (Hours)	63	0	63
Cost Burden (Dollars)	0	0	0

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Abstract: A reporting form for congenital syphilis (CDC Form 73.126) was initiated in 1983 to improve detection, case management, and treatment of congenital syphilis cases. The CDC continues to gather and report information on congenital syphilis morbidity as part of its ongoing Sexually Transmitted Disease (STD) surveillance efforts. This request includes numerous variable changes to collect pertinent data and enable appropriate classification of congenital syphilis cases.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 47072	08/07/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 73470	12/10/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Congenital Syphilis (CS) Case Investigation and Report Form: Local Health Department	none	Congenital Syphilis Case Investigation and Report
Congenital Syphilis (CS) Case Investigation and Report Form Territorial Health Agencies	none	Congenital Syphilis Case Investigation and Report
Congenital Syphilis (CS) Case Investigation and Report Form: City and county health departments	none	Congenital Syphilis Case Investigation and Report

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	187	187	0	0	0	0
Annual Time Burden (Hours)	63	63	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $97,057

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/10/2012

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