Information Collection

Cognitive testing of maternal health in local jails survey

IC 275986 under ICR 202605-1121-001 · OMB unassigned.

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: Unchanged

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
	Requested	Previously Approved
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.

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