Fertility Knowledge Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0937-0208 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Fertility Knowledge Survey Form
1 Fertility Knowledge Survey Attach_B_FertilityKnowledgeSurvey_PRAVersion_2-22-19_ROCIS.pdf Form
Attach_E_OMB_Invitation_AdultKP&AllYP_2-5-19_R.pdf Adult invitation IC Document
Attach_F_OMB_Invitation_Parent_Child_2-5-19_R.pdf Parent invitation IC Document
Attach_G_OMB_Consent_Adult_2-5-19.pdf Adult consent IC Document
Attach_H_OMB_Parent Permission_KPMinors_2-5-19.pdf Parent permission IC Document
Attach_I_OMB_Minor Assent_2-5-19.pdf Minor agreement IC Document
Attach_J_OMB_Reminder_All_2-5-19_R.pdf Reminder IC Document
Attach_K_OMB_BillofRights_TheDeal_2-5-19_ToUpdate.pdf Bill of rights IC Document
Attach_L_OMB_KPMemberPrivacyStatement_2-5-19_ToUpdate.pdf Privacy statement IC Document
Attach_M_OMB_IpsosPrivacyCommitment_2-5-19.pdf Privacy committment IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Fertility Knowledge Survey	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	1	Fertility Knowledge Survey	Attach_B_FertilityKnowledgeSurvey_PRAVersion_2-22-19_ROCIS.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	1,333	1,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Adult invitation	Attach_E_OMB_Invitation_AdultKP&AllYP_2-5-19_R.pdf	02/22/2019
Parent invitation	Attach_F_OMB_Invitation_Parent_Child_2-5-19_R.pdf	02/22/2019
Adult consent	Attach_G_OMB_Consent_Adult_2-5-19.pdf	02/22/2019
Parent permission	Attach_H_OMB_Parent Permission_KPMinors_2-5-19.pdf	02/22/2019
Minor agreement	Attach_I_OMB_Minor Assent_2-5-19.pdf	02/22/2019
Reminder	Attach_J_OMB_Reminder_All_2-5-19_R.pdf	02/22/2019
Bill of rights	Attach_K_OMB_BillofRights_TheDeal_2-5-19_ToUpdate.pdf	02/22/2019
Privacy statement	Attach_L_OMB_KPMemberPrivacyStatement_2-5-19_ToUpdate.pdf	02/22/2019
Privacy committment	Attach_M_OMB_IpsosPrivacyCommitment_2-5-19.pdf	02/22/2019

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