Information Collection

Infant Enrollment and Delivery Questionnaire

IC 227421 under ICR 201706-0920-003 · OMB 0920-1189.

Documents and Forms

Document Name Document Type
Infant Enrollment and Delivery Questionnaire Form and Instruction
Infant Enrollment and Delivery Questionnaire - English Att C5 - Infant Enrollment and Delivery Questionnaire.docx Form and Instruction
Infant Enrollment and Delivery Questionnaire - Spanish Att C5 - Infant enrollment and delivery_final Spanish.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Infant Enrollment and Delivery Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	NA	Infant Enrollment and Delivery Questionnaire - English	Att C5 - Infant Enrollment and Delivery Questionnaire.docx	NA	No		Paper Only
Form and Instruction	NA	Infant Enrollment and Delivery Questionnaire - Spanish	Att C5 - Infant enrollment and delivery_final Spanish.docx	NA	No		Paper Only

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records
Title: 09-20-0136, âEpidemiologic Studies and Surveillance of Disease Problems.â	FR Citation: 57 FR 62812

Number of Respondents: 150	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
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.