Information Collection

Att 4_Case Report

IC 244889 under ICR 202012-0920-005 · OMB 0920-1326.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920 Att 4_Case Report	Form
0920 Mycoplasma genitalium Treatment Failure Registry Case Re Att 4 Case Report Form_MG.docx	Form
0920 Mycoplasma genitalium Treatment Failure Registry Case Re Att 4 Case Report Form_MG.docx	Form
Att 2_MgenRegistryProtocol.docx Att 2_MgenRegistry Protocol	IC Document
Att 2_MgenRegistryProtocol.docx Att 2_MgenRegistry Protocol	IC Document
Att 3_Recruitment email_Postedits.docx Att 3_Recruitment Email_Postedits	IC Document
Att 3_Recruitment email_Postedits.docx Att 3_Recruitment Email_Postedits	IC Document

IC Title:

Att 4_Case Report

Agency IC Tracking Number:

0920-20OT

Is this a Common Form? No

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	0920	Mycoplasma genitalium Treatment Failure Registry Case Report Form	Att 4 Case Report Form_MG.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	100	100
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 2_MgenRegistry Protocol	Att 2_MgenRegistryProtocol.docx	12/11/2020
Att 3_Recruitment Email_Postedits	Att 3_Recruitment email_Postedits.docx	12/11/2020

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