OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Record-keeping for Sterilization Consent Form

IC 191181 under ICR 202501-0937-001 · OMB 0937-0166.

Documents and Forms
Document Name
Document Type
Form
Other-Form
Other-Form
Form
Form
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Record-keeping for Sterilization Consent Form
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 50.Sub Part B

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.docx No   Printable Only
Other-Form consent_for_sterilization_spanish_updated form.pdf No   Printable Only

Health Health Care Services

 

100,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 100,000 0 0 0 0 100,000
Annual IC Time Burden (Hours) 25,000 0 0 0 0 25,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
60 D FRN Renewal 2024-25748.pdf 01/13/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.