Information Collection

STD Clinic-based Surveillance

IC 190698 under ICR 200909-0920-008 · OMB 0920-0842.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0842 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
STD Clinic-based Surveillance	Form
STD Clinic-Based Surveillance SSUN_Attachment 3A_STD Clinic Based Surveillance.doc	Form

IC Title:

STD Clinic-based Surveillance

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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
Form	none	STD Clinic-Based Surveillance	SSUN_Attachment 3A_STD Clinic Based Surveillance.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	96	96
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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