Information Collection

2018 Congenital Syphilis Study

IC 231025 under ICR 201511-0920-001 · OMB 0920-0840.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0840 2018 Congenital Syphilis Study	Form and Instruction
0920-0840 Eligibility Screener - Prenatal Care Providers Att 5a-Eligibility Screener Providers.docx	Form and Instruction
0920-0840 Interview Guide - Prenatal Care Providers Att 5b-Interview guide Providers.docx	Form and Instruction
0920-0840 Eligibility Sreener - Pregnant Women Att 5c-Eligibility Screener Preg Women.docx	Form and Instruction
0920-0840 Interview Guide - Pregnant Women Att 5d-Interview guide Preg Women.docx	Form and Instruction
Att 3- Recruitment Flyer.pdf Recruitment Flyer	IC Document
Att 4a- Interview Consent Form.pdf Interview Consent Form	IC Document
Att 4b- Focus Group Consent Form.pdf Focus Group Consent Form	IC Document
Att 4c- Audio Consent Form.pdf Audio Consent Form	IC Document
Att 6a-UCSD IRB Letter of Approval.pdf UCSD IRB Approval Letter	IC Document
Att 6b-Tulane IRB Letter of Approval.pdf Tulane IRB Approval Letter	IC Document
Att 7- Research Plan.docx Research Plan	IC Document
Att 8-PD 7088 2018 Congenital Syphilis Study Project-Determination-and-Approval-Form-1.._.pdf CDC Project Determination	IC Document
Att 9-PIA CongenitalSyphils.pdf Privacy Impact Assessment	IC Document
SSA 11APR2018.docx Supporting Statement A	IC Document
SSB 11APR2018.docx Supporting Statement B	IC Document

IC Title:

2018 Congenital Syphilis Study

Agency IC Tracking Number:

0920-0840-18YY

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?	Electronic Capability
Form and Instruction	0920-0840	Eligibility Screener - Prenatal Care Providers	Att 5a-Eligibility Screener Providers.docx	NA	No	Paper Only
Form and Instruction	0920-0840	Interview Guide - Prenatal Care Providers	Att 5b-Interview guide Providers.docx	NA	No	Paper Only
Form and Instruction	0920-0840	Eligibility Sreener - Pregnant Women	Att 5c-Eligibility Screener Preg Women.docx	NA	No	Paper Only
Form and Instruction	0920-0840	Interview Guide - Pregnant Women	Att 5d-Interview guide Preg Women.docx	NA	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-20-0136 - Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 220

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	220	220
Annual IC Time Burden (Hours)	220	220
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment Flyer	Att 3- Recruitment Flyer.pdf	04/10/2018
Interview Consent Form	Att 4a- Interview Consent Form.pdf	04/10/2018
Focus Group Consent Form	Att 4b- Focus Group Consent Form.pdf	04/10/2018
Audio Consent Form	Att 4c- Audio Consent Form.pdf	04/10/2018
UCSD IRB Approval Letter	Att 6a-UCSD IRB Letter of Approval.pdf	04/10/2018
Tulane IRB Approval Letter	Att 6b-Tulane IRB Letter of Approval.pdf	04/10/2018
Research Plan	Att 7- Research Plan.docx	04/10/2018
CDC Project Determination	Att 8-PD 7088 2018 Congenital Syphilis Study Project-Determination-and-Approval-Form-1.._.pdf	04/10/2018
Privacy Impact Assessment	Att 9-PIA CongenitalSyphils.pdf	04/10/2018
Supporting Statement A	SSA 11APR2018.docx	04/11/2018
Supporting Statement B	SSB 11APR2018.docx	04/11/2018

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