Information Collection

Record-keeping for Sterilization Consent Form

IC 191181 under ICR 201506-0937-001 · OMB 0937-0166.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0937-0166 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0937-0166 Record-keeping for Sterilization Consent Form	Form
0937-0166 Sterilization Consent Form 0937-0166 Consent for Sterilization (English) - Expires 10_31_2015.docx	Form
0937-0166 transmital memo062515_145632.pdf Transimital memo	IC Document
0937-0166 60-dayFederal Register, Volume 80 Issue 127 (Thursday, July 2, 2015).htm 60-day FRN	IC Document

IC Title:

Record-keeping for Sterilization Consent Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 50.Sub Part B

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	0937-0166	Sterilization Consent Form	0937-0166 Consent for Sterilization (English) - Expires 10_31_2015.docx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

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	100,000	100,000
Annual IC Time Burden (Hours)	25,000	25,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Transimital memo	0937-0166 transmital memo062515_145632.pdf	09/24/2015
60-day FRN	0937-0166 60-dayFederal Register, Volume 80 Issue 127 (Thursday, July 2, 2015).htm	09/24/2015

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