Consent For Sterilization Page 2


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)


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