Information Collection

Alabama Safe Sleep Outreach Project

IC 224261 under ICR 201403-0925-009 · OMB 0925-0701.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0701 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Alabama Safe Sleep Outreach Project	Form
1 Alabama Outreach Activity Tracking form 0925-0701_Substudy_AlabamaOutreach_Activity_Tracking - 10.26.16.pdf	Form
2 Alabama Outreach Assessment Form 0925-0701_Substudy_AlabamaOutreach_Assessment_Form.pdf	Form
3 Alabama Outreach Photo Video Consent Form 0925-0701_Substudy_AlabamaOutreach_Photo_Video_Consent_Form.pdf	Form
4 Alabama Outreach Required Form 0925-0701_Substudy_AlabamaOutreach_Required_Forms.pdf	Form
5 Alabama Outreach Sign In Sheet 0925-0701_Substudy_AlabamaOutreach_Sign_In_Sheet.pdf	Form
0925-0701_Substudy_AlabamaOutreach_ MiniSSA 11.1.16.docx Mini SSA Alabama Safe Sleep Outreach	IC Document
0925-0701_Substudy_AlabamaOutreach_ MiniSSB 10.26.16.docx Mini SSB Alabama Safe Sleep Outreach	IC Document

IC Title:

Alabama Safe Sleep Outreach Project

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	1	Alabama Outreach Activity Tracking form	0925-0701_Substudy_AlabamaOutreach_Activity_Tracking - 10.26.16.pdf	No	Paper Only
Form	2	Alabama Outreach Assessment Form	0925-0701_Substudy_AlabamaOutreach_Assessment_Form.pdf	No	Paper Only
Form	3	Alabama Outreach Photo Video Consent Form	0925-0701_Substudy_AlabamaOutreach_Photo_Video_Consent_Form.pdf	No	Paper Only
Form	4	Alabama Outreach Required Form	0925-0701_Substudy_AlabamaOutreach_Required_Forms.pdf	No	Paper Only
Form	5	Alabama Outreach Sign In Sheet	0925-0701_Substudy_AlabamaOutreach_Sign_In_Sheet.pdf	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service,

FR Citation: 67 FR 70642

Number of Respondents: 2,630

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
Annual Number of Responses for this IC	2,630	2,630
Annual IC Time Burden (Hours)	319	319
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Mini SSA Alabama Safe Sleep Outreach	0925-0701_Substudy_AlabamaOutreach_ MiniSSA 11.1.16.docx	11/01/2016
Mini SSB Alabama Safe Sleep Outreach	0925-0701_Substudy_AlabamaOutreach_ MiniSSB 10.26.16.docx	11/01/2016

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