OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Form 1 - Demographic/Clinical Data

IC 6747 under ICR 201307-0920-009 · OMB 0920-0307.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0307 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC73.60A Form 1 - Demographic/Clinical Data	Form
CDC73.60A Form 1: Demographic/Clinical Data Att 3a_Demo_ClinicData_FINAL.pdf	Form
Att 3_Proposed Changes_FINAL.docx Att 3_Proposed Changes_FINAL	IC Document
Att 4_Screenshots_FINAL.doc Att 4_Screenshots_FINAL	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Form 1 - Demographic/Clinical Data

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	CDC73.60A	Form 1: Demographic/Clinical Data	Att 3a_Demo_ClinicData_FINAL.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	7,200	0	0	0	0	7,200
Annual IC Time Burden (Hours)	1,320	0	0	0	0	1,320
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 3_Proposed Changes_FINAL	Att 3_Proposed Changes_FINAL.docx	07/18/2013
Att 4_Screenshots_FINAL	Att 4_Screenshots_FINAL.doc	07/18/2013

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