Information Collection

Form 1 - Demographic/Clinical Data

IC 6747 under ICR 201012-0920-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 1 - Demographic/Clinical Data	Form
GISP Demographic/Clinical Data 0920-0307_GISP_Attachment 3a - Form 1 - 08.31.2010.doc	Form
Final-0920-0307_GISP_Att 4 - screenshots.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
Form	none	GISP Demographic/Clinical Data	0920-0307_GISP_Attachment 3a - Form 1 - 08.31.2010.doc		Yes	No	Paper Only

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	Previously Approved
Annual Number of Responses for this IC	7,200	7,200
Annual IC Time Burden (Hours)	1,320	1,320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screen shots	Final-0920-0307_GISP_Att 4 - screenshots.doc	10/28/2010

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