Survey of Title X Clinic Providers

Monitoring Changes in Attitudes and Practices among Family Planning Providers and Clinics

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.