Reproductive Medical History

The Hispanic Community Health Study/ Study of Latinos (HCHS/SOL)(NHLBI)

Documents and Forms

Document Name Document Type
Form 1 Reproductive Medical History Form and Instruction
1 RME-Repro and Medical History-Eng RME-Repro and Medical Hx-Eng.pdf Form and Instruction
RMS-Repro and Medical Hx-Span.pdf RMS-Repro and Medical History-Span IC Document

Information Collection (IC) Details

IC Title:	Reproductive Medical History	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	1	RME-Repro and Medical History-Eng	RME-Repro and Medical Hx-Eng.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,000	9,000
Annual IC Time Burden (Hours)	1,350	1,350
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
RMS-Repro and Medical History-Span	RMS-Repro and Medical Hx-Span.pdf	06/23/2014

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