Information Collection

Parent-Caregiver & Child Death Interview

IC 210020 under ICR 201407-0925-005 · OMB 0925-0593.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 28.1 Revised Parent-Caregiver & Child Death Interview	Form and Instruction
28.1 Revised Survey ParentGuardianDeathQuestionnaire_REVISED.docx	Form and Instruction
28.2 Revised Survey ChildDeathQuestionnaire_REVISED.docx	Form and Instruction
Attach 17. Authorization for Release of Child Death Certificate.docx DeathCertificateReleaseAuthorizationForm-Child	IC Document
Attach 18. Authorization for Release of Parent_Guardian Death Certificate.docx DeathCertificateReleaseAuthorizationForm-Parent_Guardian	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	28.1 Revised	Survey	ParentGuardianDeathQuestionnaire_REVISED.docx		Yes	Yes	Paper Only
Form and Instruction	28.2 Revised	Survey	ChildDeathQuestionnaire_REVISED.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: 7

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	7	7
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
DeathCertificateReleaseAuthorizationForm-Child	Attach 17. Authorization for Release of Child Death Certificate.docx	07/24/2014
DeathCertificateReleaseAuthorizationForm-Parent_Guardian	Attach 18. Authorization for Release of Parent_Guardian Death Certificate.docx	07/24/2014

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