Information Collection

Congenital Syphilis (CS) Case Investigation and Report Form: Local Health Department

IC 6642 under ICR 201212-0920-005 · OMB 0920-0128.

Documents and Forms

Document Name Document Type
Congenital Syphilis (CS) Case Investigation and Report Form: Local Health Department Form
Congenital Syphilis Case Investigation and Report Att3c Congenital Form.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Congenital Syphilis (CS) Case Investigation and Report Form: Local Health Department	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Congenital Syphilis Case Investigation and Report	Att3c Congenital Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Previously Approved
Annual Number of Responses for this IC	110	110
Annual IC Time Burden (Hours)	37	37
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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