Hospital Staff List

Attachment A1b: Hospital Staffing List

Form Approved

OMB No. 0920-0729

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)), and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA; Title 5 of Public-Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

CDC estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-0729).

Exp. Date 09/30/2020

Birth Registrars

Name (Last, First)	Work Email Address

Managers of Birth Registrars

Name (Last, First)	Work Email Address

Labor and Delivery Nurses (Including nurse/midwives)

Name (Last, First)	Work Email Address

Obstetricians and Gynecologists

Name (Last, First)	Work Email Address