Congenital Syphilis (CS) Case Investigation and Report Form Territorial Health Agencies

Congenital Syphilis Case Investigation and Report Form

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 0920-0128 Congenital Syphilis (CS) Case Investigation and Report Form Territorial Health Agencies Form and Instruction
0920-0128 Congenital Syphilis Case Investigation and Report Form 0920-0128_Attachment3c RvsdCSform2.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Congenital Syphilis (CS) Case Investigation and Report Form Territorial Health Agencies	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 and Instruction	0920-0128	Congenital Syphilis Case Investigation and Report Form	0920-0128_Attachment3c RvsdCSform2.pdf		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	33	-87	120
Annual IC Time Burden (Hours)	11	-49	60
Annual IC Cost Burden (Dollars)	0	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.