Information Collection

Intro Phone Script including Consent to Supplemental Stillbirth

IC 222820 under ICR 201608-0920-002 · OMB 0920-0010.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
AttR1_StillbirthPilot_IntroPhoneScript_English.docx	Other-WORD
AttR2_StillbirthPilot_IntroPhoneScript_Spanish.docx	Other-Word
Supplemental Stillbirth Computer Assisted Telephone Inte AttI1_BDSTEPS_SB-Suppl Questionnaire_English.docx	Form
Supplemental Stillbirth Computer Assisted Telphone Inter AttI2_BDSTEPS_SB-Suppl Questionnaire_Spanish.docx	Form

IC Title:

Intro Phone Script including Consent to Supplemental Stillbirth

Agency IC Tracking Number:

0920-0010

Is this a Common Form? No

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			AttR1_StillbirthPilot_IntroPhoneScript_English.docx	No		Paper Only
Other-Word			AttR2_StillbirthPilot_IntroPhoneScript_Spanish.docx	No		Paper Only
Form	N/A	Supplemental Stillbirth Computer Assisted Telephone Interview	AttI1_BDSTEPS_SB-Suppl Questionnaire_English.docx	Yes	Yes	Fillable Printable
Form	N/A	Supplemental Stillbirth Computer Assisted Telphone Interview	AttI2_BDSTEPS_SB-Suppl Questionnaire_Spanish.docx	Yes	Yes	Fillable Printable

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: 710

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	710	710
Annual IC Time Burden (Hours)	296	296
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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