STD Clinics (Waiting Room) Survey

[NCHHSTP] The STD Surveillance Network (SSuN)

Documents and Forms

Document Name Document Type
Form 0920-1072 STD Clinics (Waiting Room) Survey Form and Instruction
0920-1072 SSuN Gonorrhea and Syphilis Patient Interview & STD Clin Att 8_Interview Forms_Clean.docx Form and Instruction
0920-1072 SSuN Data Elements Att 5_SSuN Data Elements_Clean.xlsx Form and Instruction

Information Collection (IC) Details

IC Title:	STD Clinics (Waiting Room) Survey	Agency IC Tracking Number:	0920-1072

Is this a Common Form? No		IC Status: Modified

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 and Instruction	0920-1072	SSuN Gonorrhea and Syphilis Patient Interview & STD Clinic Patient Questionnaire	Att 8_Interview Forms_Clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1072	SSuN Data Elements	Att 5_SSuN Data Elements_Clean.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

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.