Information Collection

Fertility Knowledge Survey

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

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_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

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.