Consent For Sterilization (Page 2 of 2) in pdf

Consent For Sterilization Page 2

PAPERWORK REDUCTION ACT STATEMENT

A Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information

unless it displays the currently valid OMB control number. Public reporting burden for this collection of information will

vary; however, we estimate an average of one hour per response, including for reviewing instructions, gathering and

maintaining the necessary data, and disclosing the information. Send any comment regarding the burden estimate or

any other aspect of this collection of information to the OS Reports Clearance Officer, ASBTF/Budget Room 503 HHH

Building, 200 Independence Avenue, SW., Washington, DC 20201.

Respondents should be informed that the collection of information requested on this form is authorized by 42 CFR part

50, subpart B, relating to the sterilization of persons in federally assisted public health programs. The purpose of

requesting this information is to ensure that individuals requesting sterilization receive information regarding the risks,

benefits and consequences, and to assure the voluntary and informed consent of all persons undergoing sterilization

procedures in federally assisted public health programs. Although not required, respondents are requested to supply

information on their race and ethnicity. Failure to provide the other information requested on this consent form, and to

sign this consent form, may result in an inability to receive sterilization procedures funded through federally assisted

public health programs.

All information as to personal facts and circumstances obtained through this form will be held confidential, and not

disclosed without the individual’s consent, pursuant to any applicable confidentiality regulations. [43 FR 52165, Nov. 8,

1978, as amended at 58 FR 33343, June 17, 1993; 68 FR 12308, Mar. 14, 2003]

HHS-687 (10/12)

Consent For Sterilization Page 2