Information Collection

Territorial Health Agencies

IC 204919 under ICR 201211-0920-010 · OMB 0920-0819.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form no form number Territorial Health Agencies	Form and Instruction
ATT8_Data Screens from STDMIS 5.doc.docx	Other-screen shots example of data s
no form number Information Content of Nationally STD Case Report by Dat ATT3_Data Elements.docx	Form and Instruction

IC Title:

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 and Instruction	no form number	Information Content of Nationally STD Case Report by Data Element	ATT3_Data Elements.docx		Yes	Yes	Fillable Printable
Other-screen shots example of data screen			ATT8_Data Screens from STDMIS 5.doc.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	260	260
Annual IC Time Burden (Hours)	87	87
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.