Information Collection

Survey of Title X Clinic Providers

IC 203901 under ICR 201303-0920-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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_2_25_13.pdf	Form
Provider Survey Screenshots Phase II Provider Web Survey Screen Shots_Revised 2012-12-18.pdf	Form
D2_Provider Survey Cover Sheet_02_13_13.doc D2 - Survey Cover Letter	IC Document
C1_Private Sector Cover Letter_02_13_2013.doc C1 - Private-sector Cover Letter	IC Document

IC Title:

Survey of Title X Clinic Providers

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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_2_25_13.pdf		Yes	Yes	Fillable Fileable
Form	none	Provider Survey Screenshots	Phase II Provider Web Survey Screen Shots_Revised 2012-12-18.pdf		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
	Approved	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
D2 - Survey Cover Letter	D2_Provider Survey Cover Sheet_02_13_13.doc	02/28/2013
C1 - Private-sector Cover Letter	C1_Private Sector Cover Letter_02_13_2013.doc	02/28/2013

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