Medical Record Request

Birth Defects Study to Evaluate Pregnancy exposureS (BD-STEPS)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0010 can be found here:

Documents and Forms

Document Name Document Type
Medical Record Request Form
Medical Record Release Authorization AttQ1_MedRecordReleaseForm_English.pdf Form
Medical Record Release Authorization AttQ2_MedRecordReleaseForm_Spanish.pdf Form
AttZ1_MedRecPatientRequestLtr_English.pdf Z1 - Record Release Letter IC Document
AttZ2_MedRecPatientRequestLtr_Spanish.pdf Z2 - Record Release Letter - Spanish IC Document

Information Collection (IC) Details

IC Title:	Medical Record Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Medical Record Release Authorization	AttQ1_MedRecordReleaseForm_English.pdf		Yes	No	Paper Only
Form	none	Medical Record Release Authorization	AttQ2_MedRecordReleaseForm_Spanish.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 475	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	Previously Approved
Annual Number of Responses for this IC	475	90	385
Annual IC Time Burden (Hours)	119	23	96
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Z1 - Record Release Letter	AttZ1_MedRecPatientRequestLtr_English.pdf	08/02/2016
Z2 - Record Release Letter - Spanish	AttZ2_MedRecPatientRequestLtr_Spanish.pdf	08/02/2016

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