Information Collection

PRAMS Supplemental Modules

IC 236588 under ICR 202207-0920-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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
PRAMS COVID-19 Experience Supplemental Module (English o Att 1 PRAMS COVID-19 Experience Supplement_English_Spanish_Mail and Phone.docx Form and Instruction
PRAMS COVID-19 Experience Supplemental Module (English o Att 1 PRAMS COVID-19 Experience Supplement_English_Spanish_Mail and Phone.docx Form and Instruction
PRAMS COVID-19 Experience Supplemental Module (screensho Att 2 PRAMS COVID-19 Experiences Supplement Web Survey Screenshots.docx Form and Instruction
PRAMS COVID-19 Experience Supplemental Module (screensho Att 2 PRAMS COVID-19 Experiences Supplement Web Survey Screenshots.docx Form and Instruction
PRAMS COVID-19 Vaccine Supplemental Module (English or S Att 3 PRAMS COVID-19 Vaccine Supplement_English_Spanish_Mail and Phone.docx Form and Instruction
PRAMS COVID-19 Vaccine Supplemental Module (English or S Att 3 PRAMS COVID-19 Vaccine Supplement_English_Spanish_Mail and Phone.docx Form and Instruction
PRAMS COVID-19 Vaccine Supplemental Module (screenshots Att 4 PRAMS COVID-19 Vaccine Supplement Web Survey Screenshots.docx Form and Instruction
PRAMS COVID-19 Vaccine Supplemental Module (screenshots Att 4 PRAMS COVID-19 Vaccine Supplement Web Survey Screenshots.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

Information Collection (IC) Details

View Information Collection (IC)

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:

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
Form and Instruction	n/a	PRAMS COVID-19 Experience Supplemental Module (English or Spanish, mail or phone)	Att 1 PRAMS COVID-19 Experience Supplement_English_Spanish_Mail and Phone.docx	No		Paper Only
Form and Instruction	n/a	PRAMS COVID-19 Experience Supplemental Module (screenshots of web mode)	Att 2 PRAMS COVID-19 Experiences Supplement Web Survey Screenshots.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	PRAMS COVID-19 Vaccine Supplemental Module (English or Spanish, mail or phone)	Att 3 PRAMS COVID-19 Vaccine Supplement_English_Spanish_Mail and Phone.docx	No		Paper Only
Form and Instruction	n/a	PRAMS COVID-19 Vaccine Supplemental Module (screenshots of web mode)	Att 4 PRAMS COVID-19 Vaccine Supplement Web Survey Screenshots.docx	Yes	Yes	Fillable Fileable

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: 92,753	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	92,753	31,500	61,253
Annual IC Time Burden (Hours)	8,979	3,875	5,104
Annual IC Cost Burden (Dollars)	220,344	95,082	125,262

Documents for IC

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.