Information Collection

Pre-Pregnancy Interview

IC 193562 under ICR 201407-0925-005 · OMB 0925-0593.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2.1 Pre-Pregnancy Interview	Form and Instruction
2.1 Survey PrePregnancyQuestionnaireHousehold.docx	Form and Instruction
2.2 Survey PrePregnancyQuestionnaireAdult.docx	Form and Instruction
2.3 Survey PrePregnancySAQ.docx	Form and Instruction
HIPAAHealthUseDisclosureAuthorizationForm.docx HIPAAHealthUseDisclosureAuthorizationForm	IC Document
Attach 13. Multi-Mode Visit Information Script.docx MultiModeVisitInformationScript	IC Document
Attach 14. Sample Collection Visit Information Sheet Scripts.docx SampleCollectionVIS	IC Document
Attach 19. Reconsideration Questionnaire Adult.docx ReconsiderationQuestionnaireAdult	IC Document

IC Title:

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	2.1	Survey	PrePregnancyQuestionnaireHousehold.docx	Yes	Yes	Paper Only
Form and Instruction	2.2	Survey	PrePregnancyQuestionnaireAdult.docx	Yes	Yes	Paper Only
Form and Instruction	2.3	Survey	PrePregnancySAQ.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: 445

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	Previously Approved
Annual Number of Responses for this IC	445	445
Annual IC Time Burden (Hours)	241	241
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HIPAAHealthUseDisclosureAuthorizationForm	HIPAAHealthUseDisclosureAuthorizationForm.docx	01/13/2014
MultiModeVisitInformationScript	Attach 13. Multi-Mode Visit Information Script.docx	07/24/2014
SampleCollectionVIS	Attach 14. Sample Collection Visit Information Sheet Scripts.docx	07/24/2014
ReconsiderationQuestionnaireAdult	Attach 19. Reconsideration Questionnaire Adult.docx	07/24/2014

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