Information Collection

STD Clinic-based Surveillance

IC 190698 under ICR 201207-0920-007 · OMB 0920-0842.

Documents and Forms

Document Name Document Type
STD Clinic-based Surveillance Form and Instruction
Att 3a - Clinic-based data elements Clinic_data_elements_burden.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	STD Clinic-based Surveillance	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Att 3a - Clinic-based data elements	Clinic_data_elements_burden.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

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 %

	Approved	Previously Approved
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

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.