Information Collection

Non-STD Clinic Data Elements

IC 232304 under ICR 202403-0920-009 · OMB 0920-1242.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 3B Non-STD Clinic Facility Data Elements.docx	Other-Data elements
Att 3B Non-STD Clinic Facility Data Elements.docx	Other-Data elements

IC Title:

Agency IC Tracking Number:

0920-17BAN

Is this a Common Form? No

IC Status: Unchanged

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
Other-Data elements					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 26

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	156	156
Annual IC Time Burden (Hours)	468	468
Annual IC Cost Burden (Dollars)	19,605	19,605

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.

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