Information Collection

Neonate Assessment at Delivery Form

IC 222497 under ICR 201710-0920-014 · OMB 0920-1143.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Neonate Assessment at Delivery Form	Form and Instruction
Neonate Assessment at Delivery Form ATT_C_USZPR_Neonate_Assessment_At_Delivery_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	Neonate Assessment at Delivery Form	ATT_C_USZPR_Neonate_Assessment_At_Delivery_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: 600

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	6,000	-5,000	11,000
Annual IC Time Burden (Hours)	3,000	-2,500	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.