Form 1 - Demographic/Clinical Data

Gonococcal Isolate Surveillance Project

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0307 can be found here:

Documents and Forms

Document Name Document Type
Att3a_Form 1 _DemographicClinical Data.doc Other-WORD
Att4_Screen shots.doc Screen Shots IC Document

Information Collection (IC) Details

IC Title:	Form 1 - Demographic/Clinical Data	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-WORD			Att3a_Form 1 _DemographicClinical Data.doc		No	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7,200	5,556	1,644
Annual IC Time Burden (Hours)	1,320	-6,822	8,142
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Screen Shots	Att4_Screen shots.doc	11/29/2007

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