Information Collection

PRAMS Stillbirth Survey

IC 236591 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⚠️ Notice: This information collection may be referencing outdated material.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 Stillbirth Survey	Form and Instruction
PRAMS Stillbirth Mail Questionnaire (English) Att 8a-PRAMS UT Stillbirth Questionnaire Mail_English.pdf	Form and Instruction
PRAMS Stillbirth Mail Questionnaire (English) Att 8a-PRAMS UT Stillbirth Questionnaire Mail_English.pdf	Form and Instruction
PRAMS Stillbirth Mail Questionnaire (Spanish) Att 8b-PRAMS UT Stillbirth Questionnaire Mail_Spanish.pdf	Form and Instruction
PRAMS Stillbirth Mail Questionnaire (Spanish) Att 8b-PRAMS UT Stillbirth Questionnaire Mail_Spanish.pdf	Form and Instruction
PRAMS Stillbirth Phone Questionnaire (English) Att 8c-PRAMS UT Stillbirth Phone Questionnaire_English.docx	Form and Instruction
PRAMS Stillbirth Phone Questionnaire (English) Att 8c-PRAMS UT Stillbirth Phone Questionnaire_English.docx	Form and Instruction
PRAMS Stillbirth Phone Questionnaire (Spanish) Att 8d-PRAMS UT Stillbirth Phone Questionnaire_Spanish.docx	Form and Instruction
PRAMS Stillbirth Phone Questionnaire (Spanish) Att 8d-PRAMS UT Stillbirth Phone Questionnaire_Spanish.docx	Form and Instruction
Att 12c-PRAMS Stillbirth Introduction and Informed Consent Mail_English.docx Introduction and Informed Consent for the Stillbirth Mail Survey (English)	IC Document
Att 12c-PRAMS Stillbirth Introduction and Informed Consent Mail_English.docx Introduction and Informed Consent for the Stillbirth Mail Survey (English)	IC Document
Att 12d-PRAMS Stillbirth Introduction and Informed Consent Mail_Spanish.docx Introduction and Informed Consent for the Stillbirth Mail Survey (Spanish)	IC Document
Att 12d-PRAMS Stillbirth Introduction and Informed Consent Mail_Spanish.docx Introduction and Informed Consent for the Stillbirth Mail Survey (Spanish)	IC Document
Att 12g-PRAMS Stillbirth Introduction and Informed Consent_Phone_English.docx Introduction and Informed Consent for the Stillbirth Phone Survey (English)	IC Document
Att 12g-PRAMS Stillbirth Introduction and Informed Consent_Phone_English.docx Introduction and Informed Consent for the Stillbirth Phone Survey (English)	IC Document
Att 12h-PRAMS Stillbirth Introduction and Informed Consent_Phone_Spanish.docx Introduction and Informed Consent for the Stillbirth Phone Survey (Spanish)	IC Document
Att 12h-PRAMS Stillbirth Introduction and Informed Consent_Phone_Spanish.docx Introduction and Informed Consent for the Stillbirth Phone Survey (Spanish)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

PRAMS Stillbirth Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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?	Electronic Capability
Form and Instruction	n/a	PRAMS Stillbirth Mail Questionnaire (English)	Att 8a-PRAMS UT Stillbirth Questionnaire Mail_English.pdf	No	Paper Only
Form and Instruction	n/a	PRAMS Stillbirth Mail Questionnaire (Spanish)	Att 8b-PRAMS UT Stillbirth Questionnaire Mail_Spanish.pdf	No	Paper Only
Form and Instruction	n/a	PRAMS Stillbirth Phone Questionnaire (English)	Att 8c-PRAMS UT Stillbirth Phone Questionnaire_English.docx	No	Paper Only
Form and Instruction	n/a	PRAMS Stillbirth Phone Questionnaire (Spanish)	Att 8d-PRAMS UT Stillbirth Phone Questionnaire_Spanish.docx	No	Paper Only

Federal Enterprise Architecture Business Reference Module

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: 160

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	160	160
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	1,636	1,636

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Introduction and Informed Consent for the Stillbirth Mail Survey (English)	Att 12c-PRAMS Stillbirth Introduction and Informed Consent Mail_English.docx	06/20/2019
Introduction and Informed Consent for the Stillbirth Mail Survey (Spanish)	Att 12d-PRAMS Stillbirth Introduction and Informed Consent Mail_Spanish.docx	06/20/2019
Introduction and Informed Consent for the Stillbirth Phone Survey (English)	Att 12g-PRAMS Stillbirth Introduction and Informed Consent_Phone_English.docx	06/20/2019
Introduction and Informed Consent for the Stillbirth Phone Survey (Spanish)	Att 12h-PRAMS Stillbirth Introduction and Informed Consent_Phone_Spanish.docx	06/20/2019

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