Information Collection

Congenital Syphilis (CS) Case Investigation and Report Form: City and county health departments

IC 192057 under ICR 201212-0920-005 · OMB 0920-0128.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Congenital Syphilis (CS) Case Investigation and Report Form: City and county health departments	Form
Congenital Syphilis Case Investigation and Report Att3c Congenital Form.docx	Form

IC Title:

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	none	Congenital Syphilis Case Investigation and Report	Att3c Congenital Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	44	44
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.