Information Collection

Cognitive testing of maternal health in local jails survey

IC 275986 under ICR 202504-1121-002 · OMB 1121-0339.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1121-0339 Understanding Maternal Health in Local Jails Cognitive testing of maternal health in local jails survey	Form and Instruction
1121-0339 Understanding Maternal Health in Local Jails Attachment A - Instrument.pdf	Form and Instruction
BJS-SSP_Maternal_Health_Generic Clearance Memo - 05-29-25.docx Maternal Health in Local Jails Memo	IC Document
Generic Clearance IC Template 1121-0339_SSPMaternalHealth.docx Maternal Health GEN IC template	IC Document
All SSP Maternal Health Attachments.pdf All SSP Maternal Health Attachments	IC Document
Attachment A - Instrument.pdf Attachment A - Instrument	IC Document

IC Title:

Agency IC Tracking Number:

BJS

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	1121-0339				Yes	Yes	Fillable Fileable

Line of Business: Correctional Activities

Subfunction: Criminal Incarceration

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	115	115
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Maternal Health in Local Jails Memo		06/30/2025
Maternal Health GEN IC template		06/30/2025
All SSP Maternal Health Attachments		07/01/2025
Attachment A - Instrument		07/11/2025

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].