Information Collection

Congenital Syphilis Case Investigation And Reporting Form

IC 110746 under ICR 199403-0920-004 · OMB 0920-0128.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0128 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	CONGENITAL SYPHILIS CASE INVESTIGATION AND REPORTING FORM	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	73.126				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 65	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	875	875
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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