CLINIC VISIT RECORD FOR FAMILY PLANNING SERVICES

ICR 197910-0937-004

OMB: 0937-0005

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
165981 Migrated
ICR Details
0937-0005 197910-0937-004
Historical Active 197910-0937-002
HHS/OASH
CLINIC VISIT RECORD FOR FAMILY PLANNING SERVICES
No material or nonsubstantive change to a currently approved collection   No
Emergency 10/23/1979
Approved with change 10/23/1979
Retrieve Notice of Action (NOA) 10/23/1979
  Inventory as of this Action Requested Previously Approved
12/31/1980 12/31/1980 12/31/1980
320,000 0 320,000
48,000 0 48,000
0 0 0

THIS SURVEY PROVIDES INFORMATION ABOUT CHARACTERISTICS OF RECIPIENTS OF MEDICAL FAMILY PLANNING SERVICES AT FAMILY PLANNING SERVICE SITES THROUGHOUT THE U.S. AND SOME OF ITS TERRITORIES. IN ADDITION TO USE BY HEALTH RESEARCHERS, PLANNERS AND POLICY MAKERS IN GENERAL, IT IS USED BY THE DHHS OFFICE OF THE ASSISTANT SECRETARY FOR POPULATION AFFAIRS TO ASSESS FEDERAL FAMILY PLANNING PROGRAMS.

None
None


No

1
IC Title Form No. Form Name
CLINIC VISIT RECORD FOR FAMILY PLANNING SERVICES PHS 6138-1, THRU 14, PHS6138-1, PHS6138-14

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 320,000 320,000 0 0 0 0
Annual Time Burden (Hours) 48,000 48,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
10/23/1979


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