Information Collection

Territorial Health Agencies

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Territorial Health Agencies	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	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 %

	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

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.