Att 4_Case Report

Mycoplasma Genitalium Treatment Failure Registry

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.