Information Collection

Assessment of STD Service Needs and Provisions

IC 232609 under ICR 201511-0920-001 · OMB 0920-0840.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Assessment of STD Service Needs and Provisions	Form
Patient Questionnaire Att 3a1 Patient Questioannaire.docx	Form
Administrative Questionnaire Att 3b Administrative Questionnaire.docx	Form
SSA 8.8.18.doc Supporting Statement A	IC Document
SSB-2.doc Supporting Statement B	IC Document
Att 4 Consent_Assent Form.docx Consent/Assent	IC Document
Att 5b prior participant-letterhead.pdf Recruitment Letter - Prior Participant	IC Document
Att 5a new participant-letterhead.pdf Recruitment Letter - New Participant	IC Document
Att 6 Visit Script.docx Instruction Script	IC Document
Att 7 Privacy Impact Assessment_PIA.pdf PIA	IC Document
Project-Determination-and-Approval-Form.pdf Project Determination	IC Document

IC Title:

Assessment of STD Service Needs and Provisions

Agency IC Tracking Number:

0920-0840-18ANV

IC Status: New

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	Patient Questionnaire	Att 3a1 Patient Questioannaire.docx		No		Paper Only
Form	none	Administrative Questionnaire	Att 3b Administrative Questionnaire.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,025

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,025	5,025
Annual IC Time Burden (Hours)	421	421
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	SSA 8.8.18.doc	08/09/2018
Supporting Statement B	SSB-2.doc	08/09/2018
Consent/Assent	Att 4 Consent_Assent Form.docx	08/09/2018
Recruitment Letter - Prior Participant	Att 5b prior participant-letterhead.pdf	08/09/2018
Recruitment Letter - New Participant	Att 5a new participant-letterhead.pdf	08/09/2018
Instruction Script	Att 6 Visit Script.docx	08/09/2018
PIA	Att 7 Privacy Impact Assessment_PIA.pdf	08/09/2018
Project Determination	Project-Determination-and-Approval-Form.pdf	08/09/2018

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