Information Collection

STD Clinic Survey

IC 241634 under ICR 202004-0920-024 · OMB 0920-1072.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1072 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1072 STD Clinic Survey	Form and Instruction
0920-1072 STD Interview Att8_InterviewForms.pdf	Form and Instruction

IC Title:

STD Clinic Survey

Agency IC Tracking Number:

0920-1072

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	0920-1072	STD Interview	Att8_InterviewForms.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,850

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	3,850	3,850
Annual IC Time Burden (Hours)	321	321
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.