Survey of Title X Clinic Administrators

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⚠️ Notice: This information collection may be referencing outdated material.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 Administrators Form
Survey of Administrators of Publicly-funded Health Cente E1_Administrator Survey_2_25_13.pdf Form
Administrator Survey Screenshots Phase II Administrator Web Survey Screen Shots_Revised 2012-12-18.pdf Form
E2_Administrator Survey Cover Sheet_02_13_13.docx Administrator Survey Cover Letter IC Document
C2_Public Sector Cover Letter_02_13_13.doc C2 - Public-sector Cover Letter IC Document

Information Collection (IC) Details

IC Title:	Survey of Title X Clinic Administrators	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 Administrators of Publicly-funded Health Centers that Provide Family Planning Services	E1_Administrator Survey_2_25_13.pdf		Yes	Yes	Fillable Fileable
Form	none	Administrator Survey Screenshots	Phase II Administrator 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)	1,333	1,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Administrator Survey Cover Letter	E2_Administrator Survey Cover Sheet_02_13_13.docx	02/28/2013
C2 - Public-sector Cover Letter	C2_Public Sector Cover Letter_02_13_13.doc	02/28/2013

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