Information Collection

PRAMS Stillbirth Survey

IC 236591 under ICR 202211-0920-018 · 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⚠️ Notice: This information collection may be referencing outdated material.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 9a - PRAMS UT Stillbirth Questionnaire Mail_ENGLISH.pdf	Form and Instruction
PRAMS Stillbirth Mail Questionnaire (English) Att 9a - PRAMS UT Stillbirth Questionnaire Mail_ENGLISH.pdf	Form and Instruction
PRAMS Stillbirth Mail Questionnaire (Spanish) Att 9b - PRAMS UT Stillbirth Questionnaire Mail_SPANISH.pdf	Form and Instruction
PRAMS Stillbirth Mail Questionnaire (Spanish) Att 9b - PRAMS UT Stillbirth Questionnaire Mail_SPANISH.pdf	Form and Instruction
PRAMS Stillbirth Phone Questionnaire (English) Att 9c - PRAMS UT Stillbirth Phone Questionnaire_ENGLISH.docx	Form and Instruction
PRAMS Stillbirth Phone Questionnaire (English) Att 9c - PRAMS UT Stillbirth Phone Questionnaire_ENGLISH.docx	Form and Instruction
PRAMS Stillbirth Phone Questionnaire (Spanish) Att 9d - PRAMS UT Stillbirth Phone Questionnaire_SPANISH.docx	Form and Instruction
PRAMS Stillbirth Phone Questionnaire (Spanish) Att 9d - PRAMS UT Stillbirth Phone Questionnaire_SPANISH.docx	Form and Instruction
Att 12c - Stillbirth Mail Introduction and Informed Consent_ENGLISH.docx PRAMS Stillbirth Mail Introduction and Informed Consent (English)	IC Document
Att 12c - Stillbirth Mail Introduction and Informed Consent_ENGLISH.docx PRAMS Stillbirth Mail Introduction and Informed Consent (English)	IC Document
Att 12d - Stillbirth Mail Introduction and Informed Consent - SPANISH.docx PRAMS Stillbirth Mail Introduction and Informed Consent (Spanish)	IC Document
Att 12d - Stillbirth Mail Introduction and Informed Consent - SPANISH.docx PRAMS Stillbirth Mail Introduction and Informed Consent (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: 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?	Electronic Capability
Form and Instruction	None	PRAMS Stillbirth Mail Questionnaire (English)	Att 9a - PRAMS UT Stillbirth Questionnaire Mail_ENGLISH.pdf	No	Paper Only
Form and Instruction	None	PRAMS Stillbirth Mail Questionnaire (Spanish)	Att 9b - PRAMS UT Stillbirth Questionnaire Mail_SPANISH.pdf	No	Paper Only
Form and Instruction	None	PRAMS Stillbirth Phone Questionnaire (English)	Att 9c - PRAMS UT Stillbirth Phone Questionnaire_ENGLISH.docx	No	Paper Only
Form and Instruction	None	PRAMS Stillbirth Phone Questionnaire (Spanish)	Att 9d - 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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	160	0	160
Annual IC Time Burden (Hours)	67	0	67
Annual IC Cost Burden (Dollars)	0	-1,636	1,636

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PRAMS Stillbirth Mail Introduction and Informed Consent (English)	Att 12c - Stillbirth Mail Introduction and Informed Consent_ENGLISH.docx	11/29/2022
PRAMS Stillbirth Mail Introduction and Informed Consent (Spanish)	Att 12d - Stillbirth Mail Introduction and Informed Consent - SPANISH.docx	11/29/2022

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