Information Collection

SSuN Gonorrhea & Syphilis Patient Interview (Random Sampling)

IC 232371 under ICR 202306-0920-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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 SSuN Gonorrhea & Syphilis Patient Interview (Random Sampling)	Form and Instruction
0920-1072 SSuN Gonorrhea and Syphilis Patient Interview & STD Clin Att8_InterviewForms_0920-1072_Rev2023.docx	Form and Instruction
0920-1072 SSuN Gonorrhea and Syphilis Patient Interview & STD Clin Att8_InterviewForms_0920-1072_Rev2023.docx	Form and Instruction
0920-1072 SSuN Data Elements Att5_DataElements_0920-1072_Rev2023.docx	Form and Instruction
0920-1072 SSuN Data Elements Att5_DataElements_0920-1072_Rev2023.docx	Form and Instruction

IC Title:

SSuN Gonorrhea & Syphilis Patient Interview (Random Sampling)

Agency IC Tracking Number:

0920-1072

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 and Instruction	0920-1072	SSuN Gonorrhea and Syphilis Patient Interview & STD Clinic Patient Questionnaire	Att8_InterviewForms_0920-1072_Rev2023.docx	NA	No		Fillable Fileable
Form and Instruction	0920-1072	SSuN Data Elements	Att5_DataElements_0920-1072_Rev2023.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,000

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	Previously Approved
Annual Number of Responses for this IC	7,000	-380	7,380
Annual IC Time Burden (Hours)	1,167	-63	1,230
Annual IC Cost Burden (Dollars)	0	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.