Information Collection

Pregnant Women Enrollment Questionnaire

IC 227418 under ICR 201706-0920-003 · OMB 0920-1189.

Documents and Forms

Document Name Document Type
Pregnant Women Enrollment Questionnaire Form and Instruction
Pregnant Women Enrollment Questionnaire - English Att C2 - Pregnant Woman Enrollment Questionnaire.docx Form and Instruction
Pregnant Women Enrollment Questionnaire - Spanish Att C2 - Pregnant Woman Enrollment-final Spanish.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pregnant Women Enrollment Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	NA	Pregnant Women Enrollment Questionnaire - English	Att C2 - Pregnant Woman Enrollment Questionnaire.docx	NA	No		Paper Only
Form and Instruction	NA	Pregnant Women Enrollment Questionnaire - Spanish	Att C2 - Pregnant Woman Enrollment-final Spanish.docx	NA	No		Paper Only

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records
Title: 09-20-0136, âEpidemiologic Studies and Surveillance of Disease Problems.â	FR Citation: 57 FR 62812

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	20	20
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.