Information Collection

Birth Interview

IC 193570 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⚠️ Notice: This information collection may be referencing outdated material.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 8.1 Birth Interview	Form and Instruction
8.1 Survey BirthQuestionnaireAdult.docx	Form and Instruction
8.2 Survey BirthQuestionnaireHousehold.docx	Form and Instruction
8.3 Survey BirthQuestionnaireChild.docx	Form and Instruction
BirthCertificateAuthorizationForm.doc BirthCertificateAuthorizationForm	IC Document
HIPAAHealthUseDisclosureAuthorizationForm.docx HIPAAHealthUseDisclosureAuthorizationForm	IC Document
HIPAAUseBiologicalSamplesAuthorizationForm.doc HIPAAUseBiologicalSamplesAuthorizationForm	IC Document
MultiModeVisitInformationScript.docx MultiModeVisitInformationScript	IC Document
ParentalPermissionChildParticipationBirthto6Months.docx ParentalPermissionChildParticipationBirthto6Months	IC Document
SampleCollectionVIS.docx SampleCollectionVIS	IC Document

IC Title:

Birth 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	8.1	Survey	BirthQuestionnaireAdult.docx	Yes	Yes	Paper Only
Form and Instruction	8.2	Survey	BirthQuestionnaireHousehold.docx	Yes	Yes	Paper Only
Form and Instruction	8.3	Survey	BirthQuestionnaireChild.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: 317

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	317	-824	1,141
Annual IC Time Burden (Hours)	214	-166	380
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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