Information Collection

STD Clinics (Waiting Room) Survey

IC 241634 under ICR 202503-0920-019 · OMB 0920-1072.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1072 STD Clinics (Waiting Room) Survey	Form and Instruction
Form 0920-1072 SSuN Gonorrhea and Syphilis Patient Interview & STD Clinic Patient Questionnaire STD Clinics (Waiting Room) Survey	Form and Instruction
Form 0920-1072 SSuN Data Elements 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 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
0920-1072 SSuN Data Elements Att 5_SSuN Data Elements_Clean.xlsx	Form and Instruction

IC Title:

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				Yes	Yes	Fillable Fileable
Form and Instruction	0920-1072				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 %

table that charts list of burden
	Approved	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

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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