Information Collection

Survey of Title X Clinic Administrators

IC 203903 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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 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 %

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)	1,333	1,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.