Information Collection

Survey of Title X Clinic Providers

IC 203901 under ICR 201810-0920-003 · OMB 0920-0969.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Survey of Title X Clinic Providers	Form
Survey of Health Care Providers about Family Planning At Att E-1 2018-2019 Survey of Health Care Providers about Family Planning.doc	Form
Survey of Health Care Providers about Family Planning At Att E-2 Screen shots of provider survey.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Survey of Health Care Providers about Family Planning Attitudes and Practices	Att E-1 2018-2019 Survey of Health Care Providers about Family Planning.doc		Yes	Yes	Fillable Fileable
Form	none	Survey of Health Care Providers about Family Planning Attitude and Practices - screenshots	Att E-2 Screen shots of provider survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	8,840	8,840

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.