Gonorrhea Patient Interview (Section 1)

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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-1072 Gonorrhea Patient Interview (Section 1) Form and Instruction
0920-1072 Gonorrhea Patient Interview section 1 Att 8_InterviewTemplate_GC_syphilis.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Gonorrhea Patient Interview (Section 1)	Agency IC Tracking Number:	0920-1072

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	0920-1072	Gonorrhea Patient Interview section 1	Att 8_InterviewTemplate_GC_syphilis.pdf	NA	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,492	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,492	5,492
Annual IC Time Burden (Hours)	915	915
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.