Health Center Provider Survey

Performance Monitoring of “Working with Publicly Funded Health Centers to Reduce Teen Pregnancy among Youth from Vulnerable Populations

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1156 can be found here:

Documents and Forms

Document Name Document Type
Health Center Provider Survey Form and Instruction
Att 5 Health Center Provider Survey clean Att 5 Health Center Provider Survey clean.docx Form and Instruction
Att 5a Health Center Provider Survey Online Version Att 5a Health Center Provider Survey Online Version.docx Form

Information Collection (IC) Details

IC Title:	Health Center Provider Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	N/A	Att 5 Health Center Provider Survey clean	Att 5 Health Center Provider Survey clean.docx		Yes	Yes	Fillable Printable
Form	N/A	Att 5a Health Center Provider Survey Online Version	Att 5a Health Center Provider Survey Online Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 126	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	126	126
Annual IC Time Burden (Hours)	42	42
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.