STD Clinic Data Elements

[NCCHSTP] Strengthening US Response to Resistant Gonorrhea (SURRG)

Documents and Forms

Document Name Document Type
Att 3A STD Clinic Facility Data Elements.docx Other-Data elements
Att 3A STD Clinic Facility Data Elements.docx Other-Data elements

Information Collection (IC) Details

IC Title:	STD Clinic Data Elements	Agency IC Tracking Number:	0920-17BAN

Is this a Common Form? No		IC Status: Unchanged

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
Other-Data elements			Att 3A STD Clinic Facility Data Elements.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	896	896
Annual IC Cost Burden (Dollars)	38,237	38,237

Documents for IC

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.