2018 Congenital Syphilis Study

Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.