Information Collection

Hospital-based Survey for Mothers

IC 226837 under ICR 201704-0920-006 · OMB 0920-1183.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Hospital-based Survey for Mothers	Form and Instruction
ZPER Maternal Hospital-based Questionnaire - English Att 7a Hospital-based Survey for Mothers _English.doc	Form and Instruction
ZPER Maternal Hospital-based Questionnaire - Spanish Att 7b Hospital-based Survey for Mothers_Spanish.doc.docx	Form and Instruction
Maternal Hospital-based Questionnaire - English Screensh Att 7c Hospital-based Survey for Mothers_English_tablet screenshots.pdf	Form and Instruction
ZPER Maternal Hospital-based Questionnaire - Spanish Scr Att 7d Hospital-based Survey for Mothers_Spanish_table screenshots.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	ZPER Maternal Hospital-based Questionnaire - Spanish	Att 7b Hospital-based Survey for Mothers_Spanish.doc.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Maternal Hospital-based Questionnaire - English Screenshot	Att 7c Hospital-based Survey for Mothers_English_tablet screenshots.pdf	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	ZPER Maternal Hospital-based Questionnaire - English	Att 7a Hospital-based Survey for Mothers _English.doc	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	ZPER Maternal Hospital-based Questionnaire - Spanish Screenshot	Att 7d Hospital-based Survey for Mothers_Spanish_table screenshots.pdf	NA	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: 3,120

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,120	3,120
Annual IC Time Burden (Hours)	1,300	1,300
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.