Information Collection

Infant Health Follow-Up Form

IC 222498 under ICR 201710-0920-014 · OMB 0920-1143.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Infant Health Follow-Up Form	Form and Instruction
Infant Health Follow-Up Form - 2 year ATT_1_USZPR_Infant_Follow_Up 10262017.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	Infant Health Follow-Up Form - 2 year	ATT_1_USZPR_Infant_Follow_Up 10262017.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	18,000	-15,000	33,000
Annual IC Time Burden (Hours)	4,500	-3,750	8,250
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.