Information Collection

YMSM Clinical Form

IC 224250 under ICR 201610-0920-014 · OMB 0920-1191.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 13_YMSM Clinical Form.docx	Other-WORD

IC Title:

YMSM Clinical Form

Agency IC Tracking Number:

16JD

Is this a Common Form? No

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
Other-WORD			Att 13_YMSM Clinical Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 167

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	668	668
Annual IC Time Burden (Hours)	223	223
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.