Information Collection

Form 1 - Demographic/Clinical Data

IC 6747 under ICR 200712-0920-007 · OMB 0920-0307.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att3a_Form 1 _DemographicClinical Data.doc	Other-WORD
Att4_Screen shots.doc Screen Shots	IC Document

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.