Information Collection

Survey of Title X Clinic Providers

IC 203901 under ICR 201208-0920-008 · OMB 0920-0969.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0969 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Survey of Title X Clinic Providers	Form
Survey of Health Care Providers D1_Provider Survey.doc	Form
D2_Provider Survey Cover Sheet.doc Provider Survey Cover Sheet	IC Document
C2_Public Sector Cover Letter.doc Public Sector Initial Letter	IC Document

IC Title:

Survey of Title X Clinic Providers

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
Form	none	Survey of Health Care Providers	D1_Provider Survey.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Provider Survey Cover Sheet	D2_Provider Survey Cover Sheet.doc	08/22/2012
Public Sector Initial Letter	C2_Public Sector Cover Letter.doc	08/22/2012

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