Information Collection

Fertility Knowledge Survey

IC 235067 under ICR 201902-0937-001 · OMB 0937-0208.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0937-0208 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Fertility Knowledge Survey	Form
1 Fertility Knowledge Survey Attach_B_FertilityKnowledgeSurvey_PRAVersion_2-22-19_ROCIS.pdf	Form
Attach_E_OMB_Invitation_AdultKP&AllYP_2-5-19_R.pdf Adult invitation	IC Document
Attach_F_OMB_Invitation_Parent_Child_2-5-19_R.pdf Parent invitation	IC Document
Attach_G_OMB_Consent_Adult_2-5-19.pdf Adult consent	IC Document
Attach_H_OMB_Parent Permission_KPMinors_2-5-19.pdf Parent permission	IC Document
Attach_I_OMB_Minor Assent_2-5-19.pdf Minor agreement	IC Document
Attach_J_OMB_Reminder_All_2-5-19_R.pdf Reminder	IC Document
Attach_K_OMB_BillofRights_TheDeal_2-5-19_ToUpdate.pdf Bill of rights	IC Document
Attach_L_OMB_KPMemberPrivacyStatement_2-5-19_ToUpdate.pdf Privacy statement	IC Document
Attach_M_OMB_IpsosPrivacyCommitment_2-5-19.pdf Privacy committment	IC Document

IC Title:

Fertility Knowledge Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	1	Fertility Knowledge Survey	Attach_B_FertilityKnowledgeSurvey_PRAVersion_2-22-19_ROCIS.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	1,333	1,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Adult invitation	Attach_E_OMB_Invitation_AdultKP&AllYP_2-5-19_R.pdf	02/22/2019
Parent invitation	Attach_F_OMB_Invitation_Parent_Child_2-5-19_R.pdf	02/22/2019
Adult consent	Attach_G_OMB_Consent_Adult_2-5-19.pdf	02/22/2019
Parent permission	Attach_H_OMB_Parent Permission_KPMinors_2-5-19.pdf	02/22/2019
Minor agreement	Attach_I_OMB_Minor Assent_2-5-19.pdf	02/22/2019
Reminder	Attach_J_OMB_Reminder_All_2-5-19_R.pdf	02/22/2019
Bill of rights	Attach_K_OMB_BillofRights_TheDeal_2-5-19_ToUpdate.pdf	02/22/2019
Privacy statement	Attach_L_OMB_KPMemberPrivacyStatement_2-5-19_ToUpdate.pdf	02/22/2019
Privacy committment	Attach_M_OMB_IpsosPrivacyCommitment_2-5-19.pdf	02/22/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.