Information Collection

PRAMS Supplemental Modules

IC 236588 under ICR 202203-0920-012 · OMB 0920-1273.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1273 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
PRAMS Supplemental Modules	Form and Instruction
Family History of Breast and Ovarian Cancer Supplement Att 10a-Family History Breast Ovarian Cancer Supp_English_Spanish.docx	Form and Instruction
Family History of Breast and Ovarian Cancer Supplement Att 10a-Family History Breast Ovarian Cancer Supp_English_Spanish.docx	Form and Instruction
Prescription and Illicit Opioid Use Supplement Att 10b-Opioids Supplement_English_Spanish_mail and phone.docx	Form and Instruction
Prescription and Illicit Opioid Use Supplement Att 10b-Opioids Supplement_English_Spanish_mail and phone.docx	Form and Instruction
Disabilities Supplement Att 10c-Disability Supplement_English_Spanish_mail and phone.docx	Form and Instruction
Disabilities Supplement Att 10c-Disability Supplement_English_Spanish_mail and phone.docx	Form and Instruction
0920-1273 PRAMS Social Determinants of Health (SDOH) Supplemental Appendix C SDOH supplemental module.docx	Form and Instruction
0920-1273 PRAMS Social Determinants of Health (SDOH) Supplemental Appendix C SDOH supplemental module.docx	Form and Instruction
Appendix D SDOH supplemenatl module web screenshots.docx PRAMS Social Determinants of Health (SDOH) Supplemental Module Web Mode	IC Document
Appendix D SDOH supplemenatl module web screenshots.docx PRAMS Social Determinants of Health (SDOH) Supplemental Module Web Mode	IC Document

IC Title:

PRAMS Supplemental Modules

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Family History of Breast and Ovarian Cancer Supplement	Att 10a-Family History Breast Ovarian Cancer Supp_English_Spanish.docx	No		Paper Only
Form and Instruction	n/a	Prescription and Illicit Opioid Use Supplement	Att 10b-Opioids Supplement_English_Spanish_mail and phone.docx	No		Paper Only
Form and Instruction	n/a	Disabilities Supplement	Att 10c-Disability Supplement_English_Spanish_mail and phone.docx	No		Paper Only
Form and Instruction	0920-1273	PRAMS Social Determinants of Health (SDOH) Supplemental Module	Appendix C SDOH supplemental module.docx	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies

FR Citation: 51 FR 42484

Number of Respondents: 61,253

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	Previously Approved
Annual Number of Responses for this IC	61,253	61,253
Annual IC Time Burden (Hours)	5,104	5,104
Annual IC Cost Burden (Dollars)	125,262	125,262

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PRAMS Social Determinants of Health (SDOH) Supplemental Module Web Mode	Appendix D SDOH supplemenatl module web screenshots.docx	03/30/2022

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