Information Collection

Record-keeping for Sterilization Consent Form

IC 191181 under ICR 202204-0937-001 · OMB 0937-0166.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0937-0166 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0937-0166 Record-keeping for Sterilization Consent Form	Form
consent-for-sterilization-spanish-updated form.pdf	Other-Form
consent-for-sterilization-spanish-updated form.pdf	Other-Form
0937-0166 Sterilization Consent Form 0937-0166 Consent for Sterilization (English) FORM 687 (002).docx	Form
0937-0166 Sterilization Consent Form 0937-0166 Consent for Sterilization (English) FORM 687 (002).docx	Form
2022-03130 60D FRN.pdf 60-day FRN	IC Document
2022-03130 60D FRN.pdf 60-day FRN	IC Document

IC Title:

Record-keeping for Sterilization Consent Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 50.Sub Part B

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	0937-0166	Sterilization Consent Form	0937-0166 Consent for Sterilization (English) FORM 687 (002).docx		No		Printable Only
Other-Form			consent-for-sterilization-spanish-updated form.pdf		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	25,000	25,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
60-day FRN	2022-03130 60D FRN.pdf	04/28/2022

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