Information Collection

Pregnancy Visit 2 Interview

IC 193566 under ICR 201401-0925-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 5.1 Pregnancy Visit 2 Interview	Form and Instruction
5.1 Survey PV2QuestionnaireAdult.docx	Form and Instruction
5.2 Survey PV2QuestionnnaireHousehold.docx	Form and Instruction
5.3 Survey PV2SAQ.docx	Form and Instruction
HIPAAHealthUseDisclosureAuthorizationForm.docx HIPAAHealthUseDisclosureAuthorizationForm	IC Document
HIPAAUseBiologicalSamplesAuthorizationForm.doc HIPAAUseBiologicalSamplesAuthorizationForm	IC Document
InformedConsentFormPregnantWoman.docx InformedConsentFormPregnantWoman	IC Document
MultiModeVisitInformationScript.docx MultiModeVisitInformationScript	IC Document
ParentalPermissionChildParticipationBirthto6Months.docx ParentalPermissionChildParticipationBirthto6Months	IC Document
ReconsiderationQuestionnaireAdult.docx ReconsiderationQuestionnaireAdult	IC Document
SampleCollectionVIS.docx SampleCollectionVIS	IC Document

IC Title:

Pregnancy Visit 2 Interview

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5.1	Survey	PV2QuestionnaireAdult.docx	Yes	Yes	Paper Only
Form and Instruction	5.2	Survey	PV2QuestionnnaireHousehold.docx	Yes	Yes	Paper Only
Form and Instruction	5.3	Survey	PV2SAQ.docx	Yes	Yes	Paper Only

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: 333

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	333	-1,484	1,817
Annual IC Time Burden (Hours)	303	-454	757
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HIPAAHealthUseDisclosureAuthorizationForm	HIPAAHealthUseDisclosureAuthorizationForm.docx	01/14/2014
HIPAAUseBiologicalSamplesAuthorizationForm	HIPAAUseBiologicalSamplesAuthorizationForm.doc	01/14/2014
InformedConsentFormPregnantWoman	InformedConsentFormPregnantWoman.docx	01/14/2014
MultiModeVisitInformationScript	MultiModeVisitInformationScript.docx	01/14/2014
ParentalPermissionChildParticipationBirthto6Months	ParentalPermissionChildParticipationBirthto6Months.docx	01/14/2014
ReconsiderationQuestionnaireAdult	ReconsiderationQuestionnaireAdult.docx	01/14/2014
SampleCollectionVIS	SampleCollectionVIS.docx	01/14/2014

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