Information Collection

Hospital-based Survey for Mothers

IC 227892 under ICR 201712-0920-013 · OMB 0920-1199.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Hospital-based Survey for Mothers	Form and Instruction
IN-HOSPITAL MATERNAL SURVEY: English version Att 7a Maternal Hospital Survey_English.docx	Form and Instruction
IN-HOSPITAL MATERNAL SURVEY: Spanish version Att 7b Maternal Hospital Survey_Spanish.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	IN-HOSPITAL MATERNAL SURVEY: English version	Att 7a Maternal Hospital Survey_English.docx	NA	No		Paper Only
Form and Instruction	NA	IN-HOSPITAL MATERNAL SURVEY: Spanish version	Att 7b Maternal Hospital Survey_Spanish.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

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

FR Citation: 57 FR 62812

Number of Respondents: 1,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,600	-1,390	2,990
Annual IC Time Burden (Hours)	667	-579	1,246
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.