Information Collection

Pregnancy Loss, Stillbirth, & Neonatal Death Interview

IC 202207 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⚠️ Notice: This information collection may be referencing outdated material.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 19.1 Pregnancy Loss, Stillbirth, & Neonatal Death Interview	Form and Instruction
PLSNDPhoneMedDeathReleaseLetter.docx	Instruction
PLSNDPhoneMedReleaseLetter.docx	Instruction
19.1 Survey PregnancyLossStillbirthNeonatalDeathQuestionnaire.docx	Form and Instruction
19.2 Survey PregnancyLossStillbirthNeonatalDeathSAQ.docx	Form and Instruction
PLSNDSAQReleaseLetter.docx PLSNDSAQReleaseLetter	IC Document
PLSNDMailRemindCallScript.docx PLSNDMailRemindCallScript	IC Document
PLSNDPhoneRemindCallScript.docx PLSNDPhoneRemindCallScript	IC Document

IC Title:

Pregnancy Loss, Stillbirth, & Neonatal Death 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	19.1	Survey	PregnancyLossStillbirthNeonatalDeathQuestionnaire.docx	Yes	Yes	Paper Only
Form and Instruction	19.2	Survey	PregnancyLossStillbirthNeonatalDeathSAQ.docx	Yes	Yes	Paper Only
Instruction			PLSNDPhoneMedDeathReleaseLetter.docx	Yes	Yes	Paper Only
Instruction			PLSNDPhoneMedReleaseLetter.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: 13

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	13	-37	50
Annual IC Time Burden (Hours)	4	-17	21
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PLSNDSAQReleaseLetter	PLSNDSAQReleaseLetter.docx	11/08/2013
PLSNDMailRemindCallScript	PLSNDMailRemindCallScript.docx	11/08/2013
PLSNDPhoneRemindCallScript	PLSNDPhoneRemindCallScript.docx	11/08/2013

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