Information Collection

Fertility Knowledge Survey

IC 235067 under ICR 201903-0937-003 · OMB 0937-0208.

Documents and Forms

Document Name Document Type
Form 1 Fertility Knowledge Survey Form
1 Fertility Knowledge Survey Attach_B_FertilityKnowledgeSurvey_Version20_8-13-19_PRA_Final_Clean.pdf Form
Attach_A_TitleXLeg_May2019.pdf Attachment A Title X Legislation IC Document
Attach_C_OMB_FRN_60D&30D_All.pdf Attachment C OMB FRN 60 and 30 day IC Document
Attach_D_IRB_All_Sep2019.pdf Attachment D IRB Approval IC Document
Attach_E_OMB_Invitation_AdultKP&AllYP_May2019_R_Aug2019_Clean.pdf Attachment E Email Invitation IC Document
Attach_F_OMB_Consent_Adult_Revised_May2019_R_Aug2019_Clean.pdf Attachment F Consent Form IC Document
Attach_G_OMB_Reminder_All_May2019_R_Aug2019.pdf Attachment G Email Reminder IC Document
Attach_H_OMB_BillofRights_TheDeal_May2019_R_Aug2019.pdf Attachment H Bill of Rights IC Document
Attach_I_OMB_KPMemberPrivacyStatement_May2019_R_Aug2019.pdf Attachment I Member Privacy Policy IC Document
Attach_J_OMB_IpsosPrivacyCommitment_May2019__Aug2019.pdf Attachment J Ipsos Privacy Commitment IC Document
Attach_K_CoC_All_May2019_R_Aug2019.pdf Attachment K CoC IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Fertility Knowledge Survey	Agency IC Tracking Number:

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	1	Fertility Knowledge Survey	Attach_B_FertilityKnowledgeSurvey_Version20_8-13-19_PRA_Final_Clean.pdf		No		Printable Only

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 %

	Approved	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

Title	Document	Date Uploaded
Attachment A Title X Legislation	Attach_A_TitleXLeg_May2019.pdf	10/03/2019
Attachment C OMB FRN 60 and 30 day	Attach_C_OMB_FRN_60D&30D_All.pdf	10/03/2019
Attachment D IRB Approval	Attach_D_IRB_All_Sep2019.pdf	10/03/2019
Attachment E Email Invitation	Attach_E_OMB_Invitation_AdultKP&AllYP_May2019_R_Aug2019_Clean.pdf	10/03/2019
Attachment F Consent Form	Attach_F_OMB_Consent_Adult_Revised_May2019_R_Aug2019_Clean.pdf	10/03/2019
Attachment G Email Reminder	Attach_G_OMB_Reminder_All_May2019_R_Aug2019.pdf	10/03/2019
Attachment H Bill of Rights	Attach_H_OMB_BillofRights_TheDeal_May2019_R_Aug2019.pdf	10/03/2019
Attachment I Member Privacy Policy	Attach_I_OMB_KPMemberPrivacyStatement_May2019_R_Aug2019.pdf	10/03/2019
Attachment J Ipsos Privacy Commitment	Attach_J_OMB_IpsosPrivacyCommitment_May2019__Aug2019.pdf	10/03/2019
Attachment K CoC	Attach_K_CoC_All_May2019_R_Aug2019.pdf	10/03/2019

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