Information Collection

Hospital-based Survey for Fathers

IC 226838 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 Fathers	Form and Instruction
Hospital-based Survey for Fathers - English Att 8a Hospital-based Survey for Fathers_English.doc.docx	Form and Instruction
Hospital-based Survey for Fathers - Spanish Att 8b Hospital-based Survey for Fathers _Spanish.doc.docx	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	Hospital-based Survey for Fathers - English	Att 8a Hospital-based Survey for Fathers_English.doc.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Hospital-based Survey for Fathers - Spanish	Att 8b Hospital-based Survey for Fathers _Spanish.doc.docx	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: 1,872

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	1,872	1,872
Annual IC Time Burden (Hours)	468	468
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.