Information Collection

Pregnancy Complications History

IC 211972 under ICR 201406-0925-002 · OMB 0925-0584.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Pregnancy Complications History	Form and Instruction
1 PCE-Pregnancy Complications Hx - Eng PCE-Pregnancy Complications Hx - Eng mod June 2014.pdf	Form and Instruction
PCS-Pregnancy Complications Hx_Span mod 06232014.pdf PCS-Pregnancy Complications Hx - Span	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	PCE-Pregnancy Complications Hx - Eng	PCE-Pregnancy Complications Hx - Eng mod June 2014.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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,000	9,000
Annual IC Time Burden (Hours)	900	900
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PCS-Pregnancy Complications Hx - Span	PCS-Pregnancy Complications Hx_Span mod 06232014.pdf	06/23/2014

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