Information Collection

Cx3 Study - Initial Clinic Survey

IC 188620 under ICR 200903-0920-010 · OMB 0920-0814.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0814 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att C1_Initial Clinic Survey_0209.doc	Other-WORD
Att C1a_ Cover letter -- initial clinic survey.doc Att C1a_ Cover letter -- initial clinic survey	IC Document

IC Title:

Cx3 Study - Initial Clinic Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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			Att C1_Initial Clinic Survey_0209.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 252

Number of Respondents: 6

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
Annual Number of Responses for this IC	6	6
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att C1a_ Cover letter -- initial clinic survey	Att C1a_ Cover letter -- initial clinic survey.doc	02/23/2009

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