Gonorrhea Patient Interview

Enhanced STD Surveillance Network

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1072 can be found here:

Documents and Forms

Document Name Document Type
Gonorrhea Patient Interview Form and Instruction
Patient Interview Script Att 3D Patient Interview_DataElements.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Gonorrhea Patient Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	none	Patient Interview Script	Att 3D Patient Interview_DataElements.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,225	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,225	3,225
Annual IC Time Burden (Hours)	538	538
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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