Record-keeping for Sterilization Consent Form

42 C.F.R. Subpart B: Sterilization of Persons in Federally Assisted Family Planning Projects

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.