English Contact information Form

Congenital Heart Survey to Recognize Outcomes, Needs, and Well-Being

Documents and Forms

Document Name Document Type
Form 0920-1122 English Contact information Form Form
0920-1122 English Contact Information Form Att. 18 - English Contact Info Form (CH STRONG).docx Form

Information Collection (IC) Details

IC Title:	English Contact information Form	Agency IC Tracking Number:	0920-1122

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-1122	English Contact Information Form	Att. 18 - English Contact Info Form (CH STRONG).docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Epidemiological Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 237	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	237	237
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.