Information Collection

DSTP Assessment of STD Clinic Users

IC 206883 under ICR 201301-0920-010 · OMB 0920-0840.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 2 ConsentForm .doc	Other-Consent
DSTDP Assessment of STD Clinic Users Att 1 ClinicSurvey.doc	Form
Supporting Statement B.doc Supporting Statement B	IC Document
Supporting Statement A.doc Supporting Statement A	IC Document

IC Title:

DSTP Assessment of STD Clinic Users

Agency IC Tracking Number:

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
Other-Consent			Att 2 ConsentForm .doc		Yes	Yes	Printable Only
Form	none	DSTDP Assessment of STD Clinic Users	Att 1 ClinicSurvey.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	4,400	0	0	0	0	0
Annual IC Time Burden (Hours)	733	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement B	Supporting Statement B.doc	05/13/2013
Supporting Statement A	Supporting Statement A.doc	05/13/2013

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