Information Collection

Mother's Questionnaire

IC 6608 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⚠️ Notice: This information collection may be referencing outdated material.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
Mother's Questionnaire	Form
BD-STEPS Questionnaire AttG1_BDSTEPS_CATI_English.tfs4_kb.docx	Form
BD-STEPS Questionnaire - Spanish AttG2_BDSTEPS_CATI_SPANISH_7.3.docx	Form
AttN1_IntroPhoneScript_English.pdf N1 - Consent	IC Document
AttN2_IntroPhoneScript_Spanish.pdf N2 - Consent - Spanish	IC Document

IC Title:

Mother's Questionnaire

Agency IC Tracking Number:

0920-0010

Is this a Common Form? No

IC Status: Modified

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?	Can Be Submitted Electronically?	Electronic Capability
Form	none	BD-STEPS Questionnaire	AttG1_BDSTEPS_CATI_English.tfs4_kb.docx		Yes	Yes	Fillable Fileable
Form	none	BD-STEPS Questionnaire - Spanish	AttG2_BDSTEPS_CATI_SPANISH_7.3.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

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

FR Citation: 57 FR 62812

Number of Respondents: 2,365

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,365	440	1,925
Annual IC Time Burden (Hours)	1,774	330	1,444
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
N1 - Consent	AttN1_IntroPhoneScript_English.pdf	08/02/2016
N2 - Consent - Spanish	AttN2_IntroPhoneScript_Spanish.pdf	08/02/2016

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