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Congenital Syphilis (CS) Case Investigation and Report Form Territorial Health Agencies
Congenital Syphilis Case Investigation and Report Form
OMB: 0920-0128
IC ID: 46587
OMB.report
HHS/CDC
OMB 0920-0128
ICR 201212-0920-005
IC 46587
( )
Documents and Forms
Document Name
Document Type
Congenital Syphilis (CS) Case Investigation and Report Form Territorial Health Agencies
Form
Congenital Syphilis Case Investigation and Report
Att3c Congenital Form.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Congenital Syphilis (CS) Case Investigation and Report Form Territorial Health Agencies
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
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
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
3
Number of Respondents for Small Entity:
0
Affected Public:
Federal Government
Percentage of Respondents Reporting Electronically:
0 %
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
33
0
0
0
0
33
Annual IC Time Burden (Hours)
11
0
0
0
0
11
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
