Information Collection

Maternal Health History Form

IC 222494 under ICR 201710-0920-014 · OMB 0920-1143.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Maternal Health History Form	Form and Instruction
Maternal Health History Form ATT_A_USZPR_Maternal_Health-History_Form_Revised 21SEP2016.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

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 and Instruction	NA	Maternal Health History Form	ATT_A_USZPR_Maternal_Health-History_Form_Revised 21SEP2016.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

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

FR Citation: 57 FR 62812

Number of Respondents: 665

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	6,650	-4,350	11,000
Annual IC Time Burden (Hours)	3,325	-2,175	5,500
Annual IC Cost Burden (Dollars)	0	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.