Information Collection

Dental Professionals & Human Papillomavirus (HPV) Prevention Survey

IC 236413 under ICR 201804-0917-001 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 9017-0036 Dental Professionals & Human Papillomavirus (HPV) Prevention Survey	Form and Instruction
9017-0036 HPV Survey HPV Questionnaire_6.10.19.docx	Form and Instruction
2015 Generic Clearance Submission Template - HPV 6.10.19.doc HPV submission form	IC Document

IC Title:

Dental Professionals & Human Papillomavirus (HPV) Prevention Survey

Agency IC Tracking Number:

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 and Instruction	9017-0036	HPV Survey	HPV Questionnaire_6.10.19.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	500	500
Annual IC Time Burden (Hours)	92	92
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HPV submission form	2015 Generic Clearance Submission Template - HPV 6.10.19.doc	06/10/2019

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