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Reproductive Medical History
The Hispanic Community Health Study/ Study of Latinos (HCHS/SOL)(NHLBI)
OMB: 0925-0584
IC ID: 211971
OMB.report
HHS/NIH
OMB 0925-0584
ICR 201406-0925-002
IC 211971
( )
Documents and Forms
Document Name
Document Type
Form 1
Reproductive Medical History
Form and Instruction
1 RME-Repro and Medical History-Eng
RME-Repro and Medical Hx-Eng.pdf
Form and Instruction
RMS-Repro and Medical Hx-Span.pdf
RMS-Repro and Medical History-Span
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Reproductive Medical History
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
1
RME-Repro and Medical History-Eng
RME-Repro and Medical Hx-Eng.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
9,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
9,000
0
9,000
0
0
0
Annual IC Time Burden (Hours)
1,350
0
1,350
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
RMS-Repro and Medical History-Span
RMS-Repro and Medical Hx-Span.pdf
06/23/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.