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Record-keeping for Sterilization Consent Form
42 C.F.R. Subpart B: Sterilization of Persons in Federally Assisted Family Planning Projects
OMB: 0937-0166
IC ID: 191181
OMB.report
HHS/OASH
OMB 0937-0166
ICR 202204-0937-001
IC 191181
( )
Documents and Forms
Document Name
Document Type
Form 0937-0166
Record-keeping for Sterilization Consent Form
Form
consent-for-sterilization-spanish-updated form.pdf
Other-Form
consent-for-sterilization-spanish-updated form.pdf
Other-Form
0937-0166 Sterilization Consent Form
0937-0166 Consent for Sterilization (English) FORM 687 (002).docx
Form
0937-0166 Sterilization Consent Form
0937-0166 Consent for Sterilization (English) FORM 687 (002).docx
Form
2022-03130 60D FRN.pdf
60-day FRN
IC Document
2022-03130 60D FRN.pdf
60-day FRN
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Record-keeping for Sterilization Consent Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 50.Sub Part B
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
0937-0166
Sterilization Consent Form
0937-0166 Consent for Sterilization (English) FORM 687 (002).docx
No
Printable Only
Other-Form
consent-for-sterilization-spanish-updated form.pdf
No
Printable Only
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:
100,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
100,000
0
0
0
100,000
0
Annual IC Time Burden (Hours)
25,000
0
0
0
25,000
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
60-day FRN
2022-03130 60D FRN.pdf
04/28/2022
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.